
Class. 

Book__ 

Copyright)! - 






COPYRIGHT DEPOSIT. 



NOSE, THROAT AND EAR 



KNIGHT AND BRYANT 



DISEASES 



OF THE 



NOSE, THROAT AND EAR 



BY 

CHARLES HUNTOON KNIGHT, A.M., M. D. 

PROFESSOR OF LARYNGOLOGY, CORNELL UNIVERSITY MEDICAL COLLEGE; SURGEON, 

MANHATTAN EYE, EAR AND THROAT HOSPITAL; CONSULTING LARYNGOLOGIST, 

NEW YORK STATE HOSPITAL FOR CRIPPLED AND DEFORMED CHILDREN, ETC. 



AND 

W. SOHIER BRYANT, A.M., M.D. 

CONSULTING OTOLOGIST, MANHATTAN STATE HOSPITAL; SENIOR ASSISTANT SURGEON, 
AURAL DEPARTMENT, NEW YORK EYE AND EAR INFIRMARY, ETC. 



SECOND EDITION, REVISED 
WITH 239 ILLUSTRATIONS 



PHILADELPHIA 
P. BLAKISTON'S SON & CO 

1012 WALNUT STREET 
1909 






1/ 



Copyright, 1909, By P. Blakiston's Sox & Co. 



24.84 



Printed by 

The Maple Press 

York, Pa. 



PREFACE TO SECOND EDITION. 



In preparing a new edition of " Diseases of the Nose and Throat" 
numerous minor changes have been made throughout. The chief 
additions will be found in the chapters on Deviated Septum and 
Diseases of the Accessory Sinuses. The extraordinary activity of 
recent years in the regions concerned has led to the adoption of 
rather extreme opinions in some particulars, which time and further 
experience will probably modify. There is no doubt, however, 
that distinct progress has been made toward placing the treatment 
of deformities of the nasal septum and chronic inflammation of 
the sinuses on a more precise and scientific basis. It only remains 
to determine the limitations of new operations and to select suitable 
cases for their application. 

To those who anticipate a revolution in laryngoscopy from the 
introduction of the direct method of examination (Kirstein), which 
perhaps constitutes one of the most important advances in our 
speciality, it may seem that scant attention has been given to 
manipulations in the upper air tract in this way. Two reasons for 
this course have prevailed. In the first place, it is not likely that 
the older methods of exploration will be supplanted as a matter 
of routine. The class of cases within its scope (foreign bodies, new 
growths in children, neoplasms at the anterior commissure or below 
the vocal bands, etc.) offers a comparatively restricted field for the 
new procedure. In the second place, the special apparatus required 
and the unusual operative skill demanded are more or less prohib- 
itive as to general use. It therefore seems more judicious to leave 
detailed description to special monographs and relinquish the 
procedure itself to the few who have given the subject particular 
attention. 

In this country the industry and ingenuity of Jackson, Ingals and 
Mosher and abroad of Killian and Bruenings have combined 10 
bring the operation to a stage of almost absolute perfection. Its 
great advantage in surgical work must be admitted, but the results 

v 



VI PREFACE. 

attained by the ordinary modes of examination are in general 
satisfactory. A similar opinion applies to pharyngoscopy with the 
ingenious electric illuminator devised by Hays. In difficult and 
doubtful cases it may prove of decided utility. 

In response to many requests a section on Diseases of the Ear 
has been added. The senior author considers himself fortunate 
in having enlisted the cooperation of Dr. Bryant, to whom he wishes 
to accord all credit and responsibility for the work done and views 
expressed in that department. 

Finally the authors desire to make joint acknowledgment to their 
colleagues for helpful suggestions and to their publishers for the 
care with which their ideas have been executed. We owe especial 
thanks to Dr. Freer, of Chicago, and Dr. Jackson, of Pittsburgh, 
as well as to various surgical instrument makers for courtesy shown 
in permission to make use of certain illustrations. Many of those 
in the pages devoted to the ear are original and are now for the first 
time published. The volume is offered to the profession in the hope 
that it may be found a useful and reliable guide. 



CONTENTS. 



CHAPTER I. 

PAGE 

Anatomy and Physiology of the Nasal Passages. Methods 
or Examination. Instruments and Apparatus i 

CHAPTER II. 

Acute and Chronic Rhinitis 18 

CHAPTER III. 

Atrophic Rhinitis. Membranous Rhinitis. Caseous Rhin- 
itis. Purulent Rhinitis 43 

CHAPTER IV. 

Diseases of the Accessory Sinuses. Acute and Chronic Sinu- 
sitis. Hydrops Antri, or Serous Effusion and Cyst of 
the Antrum. Foreign Bodies and Neoplasms 55 

CHAPTER V. 

Diseases and Deformities of the Nasal Septum. Deviation, 
ecchondrosis. exostosis. ulceration. perforation. 
Hematoma. Abscess. Congenital Occlusion of the 
Naris. Adhesions. Collapse of the Nostril. Disloca- 
tion of the Columnar Cartilage. Fracture of the Nose . 96 

CHAPTER VI. 
Nasal Polypi 134 

CHAPTER VII. 

Benign Tumors and Malignant Disease of the Nasal Foss.e. 
Foreign Bodies. Rhinoliths. Epistaxis 141 

CHAPTER VIII. 

Syphilis of the Nasal Fossae. Lupus. Tuberculosis. Rhino- 
scleroma 158 

vii 



PAGE 



Vlil CONTENTS. 

CHAPTER IX. 

Nasal Neuroses. Hay Fever. Nasal Hydrorrhea 169 

CHAPTER X. 

Anatomy and Physiology of the Pharynx 181 

CHAPTER XI. 

Diseases of the Velum and Uvula. Bifid Uvula. Neoplasms 
and malignant disease of the velum. cleft palate. 
Uvulitis and Elongated Uvula. Acute and Chronic 
Pharyngitis. Atrophic Pharyngitis. Rheumatic Phar- 
yngitis 190 

CHAPTER XII. 
Adenoids in the Rhinopharynx 204 

CHAPTER XIII. 

Hypertrophied Tonsils . 221 

CHAPTER XIV. 

Diseases of the Lingual Tonsil. Abscess of the Tongue. 

Retropharyngeal Abscess. Mycosis of the Pharynx . . . 238 

CHAPTER XV. 

Tonsillitis. Diphtheria. Circumtonsillar Abscess or 

Quinsy. Ulcero-membranous or Diphtheroid Angina . . 248 

CHAPTER XVI. 

Benign Neoplasms of the Tonsil. Tonsilliths. Malignant 
Disease of the Tonsils. Tuberculosis, Lupus and Syphi- 
lis of the Pharynx. Neuroses of the Pharynx. Foreign 
Bodies in the Pharynx 264 

CHAPTER XVII. 

Anatomy and Physiology of the Larynx. Methods of Exam- 
ination 278 



CONTENTS. IX 

CHAPTER XVIII. 



PAGE 



Diseases or the Larynx. Anemia and Hyperemia. Laryngeal 
Hemorrhage. Acute and Chronic Laryngitis. Chord- 
itis tuberosa or vocal nodules. chronic subglottic 
Laryngitis. Atrophic Laryngitis 296 

CHAPTER XIX. 

Benign Neoplasms or the Larynx 308 

CHAPTER XX. 

Malignant Disease op the Larynx 323 

CHAPTER XXI. 

Tuberculosis of the Larynx 336 

CHAPTER XXII. 

Syphilis of the Larynx 354 

CHAPTER XXIII. 

Neuroses of the Larynx. Hyperesthesia. Anesthesia. Par- 
esthesia. Neuralgia. Hysterical Aphonia. Laryngeal 
Vertigo. Chorea. Spasm of the Larynx. Laryngeal 
Stridor and Whistling. Paralysis of the Larynx. . . . 362 

CHAPTER XXIV. 

Foreign Bodies in the Larynx. Prolapse of the Ventricle. 

Fracture of the Larynx . 380 

CHAPTER XXV. 

Anatomy, Development, Comparative Anatomy, Embryology 
of the Ear 391 

CHAPTER XXVI. 

Physiology, Theory of Sound Perception, Tone and Noise 
Perception. Physiology of Sound Conduction. Physi- 
ology of the Determination of the Direction of Sound. 
Physiology of Equilibration. Protective Mechanism of 
the Ear ..." 400 



X CONTENTS. 

CHAPTER XXVII. 

PAGE 

Physiopathology. Disturbances of the Auditory Function. 
Disturbances of the Equtlibrational Function. Minor 
Disturbances of Function. Central Nervous Disturb- 
ances 477 

CHAPTER XXVIII. 

Etiology of Ear Affections. Etiology of Primary Ear Dis- 
eases. Etiology of Secondary Affections of the Ear. 
i. From Pathological Conditions of Contiguous Struc- 
tures. 2. From Systemic Causes. Drugs that may Cause 
Ear Diseases. Heredity and Age. Prevention of Ear 
Disease 489 

CHAPTER XXIX. 
Examination of Patients. Dlagnosis of Ear Diseases . . 496 

CHAPTER XXX. 

Affections of the External Ear 514 

CHAPTER XXXI. 

Diseases of the Middle Ear 525 

CHAPTER XXXII. 

Diseases of the Sound Perceiving Apparatus 542 

CHAPTER XXXIII. 

The Major Surgical Diseases of the Ear and Their Com- 
plications 553 

CHAPTER XXXIV. 

Naso-pharyngeal and Constitutional Treatment of Ear 
Disease 563 

CHAPTER XXXV. 
Surgical Technic ' 566 



CONTENTS. xi 

CHAPTER XXXVI. 

PAGE 

Therapeutics of the Ear; General Therapeutics 587 



CHAPTER XXXVII. 

Special Instruments, Procedures and Appliances 596 

INDEXES. 

The Nose 611 

The Pharynx 615 

The Larynx 617 

The Ear 621 



LIST OF ILLUSTRATIONS. 



FIGURE PAGE 

i. The Nasal Septum 2 

2. Outer Wall of Nasal Fossa 3 

3. Mackenzie's Light Condenser n 

4. Kuttner's Electric Head Light n 

5. Duplay's Nasal Speculum 12 

6. Hartmann's Nasal Speculum 13 

Jarvis' Nasal Specula 13 

Jarvis' Rhinometer 14 

Seiler's Septometer 14 

Turck's Tongue Depressor 15 

Bosworth's Tongue Depressor 15 

White's Palate Hook 16 

Kyle's Postnasal Electric Lamp 16 

Lmiversal Powder Blower • 21 

DeVilbiss Nebulizer 22 

Hyperplasia of Turbinates 24 

Cyst of Middle Turbinate 26 

Microscopic Section of Turbinate Cyst 27 

Lefferts' Hand Atomizer ' . . . 28 

Woakes' Nasal Irrigator 2S 

Nasal Syringe 2S 

Sass' Glass Spray Tubes 20 

Jarvis' Snare 31 

Sajous' Snare v >2 

Wright's Snare 33 

Casselberry's Nasal Scissors 34 

Knight's Forceps and Scissors 35 

Schech's Handle for Cautery Point 36 

Schech's Handle for Cautery Loop 36 

Berens' Spoke Shave 40 

Lefferts' Postnasal Syringe 47 

Holmes' Postnasal Douche 48 

Sound in Sinus Openings 5 7 

Vertical Cross Section of Nasal Fossse 59 

Myles' Antrum Trocar and Canula 61 

xiii 



XIV LIST OF ILLUSTRATIONS 

FIGURE PAGE 

36. Lamps for Transillumination 62 

37. Myles' Antrum Tubes 66 

38. Mikulicz's Antrum Stilet 66 

39. Hartmann's Canula 67 

40. Snare Applied to Middle Turbinate 68 

41. Normal Frontal Sinuses 72 

42. Asymmetry of Frontal Sinuses 73 

43. Septa of Frontal and Sphenoidal Sinuses 74 

44. Incisions in Opening Frontal Sinus 78 

45. Hajek's Curette. Gninwald's Forceps . 85 

46. Probe in Sphenoidal Sinus 87 

47. Adams' Septum Forceps 100 

48. Nasal Drills, Trephines and Burrs 100 

49. Steele's Septum Punch 101 

50. Roe's Septum Forceps 102 

51. Moure's Osteotome 103 

52. Incisions in Moure's Operation 104 

53. Moure's Nasal Tube and Dilator 104 

54. Kyle's Operation for Deflected Septum 105 

55. Fetterolf's Saw File 106 

56. Krieg's Operation for Angular Deflection 108 

57. Freer's Instruments for Submucous Resection 109 

58. Window- Resection Operation no 

59. Ballenger's Submucous Knife in 

60. Carter's Septum Forceps 112 

61. Asch's Instruments for Deviated Septum 113 

62. Nasal Tubes 115 

63. Ecchondrosis of Septum 120 

64. Ecchondrosis of Septum 121 

65. Bosworth's Nasal Saws 122 

66. Nasal Polypi 137 

67. Section of Nasal Fibroma 141 

68. Papilloma of Septum 143 

69. Granular Turbinates and Epistaxis 152 

70. Hartmann-Kiesselbach Spot 153 

71. Bellocq's Canula 154 

72. Cooper Rose's Hemostat 155 

73. Simpson's Plug 156 

74. Bishop's Nasal Bridge 160 

75. Martin's Nasal Bridge 160 

76. Martin's Bridge in Position 161 

77. Smith's Paraffin Syringe v. 162 



LIST OF ILLUSTRATIONS. XV 



PAGE 



78. Lupus of Nose 165 

79. Tuberculosis of Turbinates 166 

80. Muscles of Soft Palate 183 

81. Constrictors of Pharynx 185 

82. Bifid Uvula 190 

83. Follicular Pharyngitis 198 

84. Adenoids in Rhinopharynx 205 

85. Adenoids seen through Anterior Nares 210 

86. Denhard's Mouth Gag 211 

87. Schuetz's Adenotome . . . .' 213 

88. Meyer's Ring Knife 215 

89. Loewenberg's Forceps 215 

90. Brandegee's Forceps 215 

91. Schuetz's Forceps 216 

92. Motais' Finger Nail 216 

93. Freer's Pernasal Forceps 216 

94. Gottstein's Curette 217 

95. Beckmann's Curette 217 

96. Knight's Forceps 217 

97. Farlow's Tonsil Snare 225 

98. Knight's Electric Snare 226 

99. Mackenzie's Tonsillotome 229 

100. Mathieu's Tonsillotome 229 

101. Farlow's Tonsil Punch 230 

102. Butts' Tonsil Hemostat 232 

103. Mikulicz-Stoerk Hemostat 232 

104. Robertson's Tonsil Scissors 235 

105. Abraham's Tonsil Knives 236 

106. Lingual Tonsil 239 

107. Roe's Lingual Tonsillotome 241 

108. Syphilitic Ulcer of Velum 272 

109. Perforation of Velum 273 

no. Muscles of Larynx, Side View 280 

in. Muscles of Larynx, Posterior View 281 

112. Posterior Cricoarytenoid Muscles 282 

113. Thyroarytenoid Muscles 283 

114. Arytenoideus Muscle - 284 

115. Nerves and Arteries of Larynx 285 

116. Larynx during Phonation 286 

117. Aperture of Larynx and Base of Tongue 287 

118. Escat's Tongue Depressor 292 

119. Papilloma of Larynx 310 



XVI LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

1 20. Fibroma of Larynx 311 

121. Cyst of Larynx 311 

122. Cyst of Epiglottis 312 

123. Subglottic Myxoma 313 

124. Mackenzie's Laryngeal Forceps 315 

125. Schroetter-Turck Canula Forceps 316 

126. Sarcoma of Larynx 323 

127. Epithelioma of Vocal Band 325 

128. Cancerous Ulceration of Larynx 326 

129. Krause's Laryngeal Set 327 

130. Tuberculosis of Larynx 340 

131. Tuberculous Ulcer and Infiltration 340 

132. Tuberculous Llcer of Larynx 341 

133. Tuberculous Tumor of Larynx 341 

134. Tuberculous Ulcer at Posterior Commissure 342 

135. Heryng's Curettes and Scarifiers 348 

136. Schroetter's Laryngeal Dilator 356 

137. Syphilis of Vocal Bands ' • • • 357 

138. Syphilis of Vocal Bands 359 

139. Syphilitic Ulceration of Bands 360 

140. Hysterical Paralysis of Adductors 364 

141. Paralysis of Internal Thyroarytenoids 372 

142. Paralysis of Arytenoideus 372 

143. Paralysis of Thyroarytenoids and Arytenoideus 372 

144. Paresis of Recurrent during Respiration 373 

145. Paresis of Recurrent during Phonation 374 

146. Paralysis of Recurrent on Phonation 374 

147. Paresis of Posterior Cricoarytenoids 375 

148. Cusco's Laryngeal Forceps 384 

149. Jackson's Spatula and Tubes 386 

150. Left Auricle 392 

151. Cast of Right Auricle and Canal Cavities viewed from within . 393 

152. Outline of Cast of Right External Auditory Canal 393 

153. Outer Surface of Right Temporal Bone 394 

154. Metallic Cast of Right Middle Ear Tract Viewed from the 

Outer side 395 

155. Pharyngeal Orifice of the Right Eustachian Tube at Rest. . 397 

156. Pharyngeal Orifice of the Right Eustachian Tube during an 

Act of Swallowing 397 

157. Eustachian Tube in Cross-section 399 

158. Outer Half of Vertical Section of Middle Ear Tract through 

Mastoid Antrum and Eustachian Tube 4°° 



LIST OF ILLUSTRATIONS. XV11 

FIGURE PAGE 

159. Vertical Section through Middle Ear shows Outer Wall of 

Cavum Tympani 401 

160. Diagram of Fibers of Membrana Propria of the Drum Mem- 

brane 401 

161. Outer Surface of Left Drum Membrane (enlarged) 402 

162. Section of Attachment of Drum Membrane to the Sulcus 

Tympanicus (enlarged) 403 

163. Inner Surface of Right Drum Membrane and Outer Wall of 

Attic (enlarged) 404 

164. Inner Wall of Left Middle Ear Tract, Vertical Section of 

Temporal Bone 405 

165. Inner Wall of Middle Ear Tract, from Eustachian Tube and 

Mastoid Antrum 406 

166. Posterior Half of Vertical Section of Right Temporal Bone 

through the external and Internal Meati, showing Posterior 
Tympanic Wall (enlarged) 407 

167. Lower Half of Horizontal Section of Right Temporal Bone 

cut through External Auditory Meatus showing the Lower 
Tympanic Wall 408 

168. Anterior Half of Vertical Section of Right Temporal Bone, 

cut through the External and Internal Auditory Meati, 
showing the Anterior Tympanic Wall (enlarged) .... 409 

169. Mastoid Right Process with Outer Table Removed, showing 

Large Cells at Base of Process and Diploe at Tip. . . .411 

170. Longitudinal Section of Hammer, Cross-section of Attic, and 

Prussack's Space, Right Ear 413 

171. Malleus (enlarged) 414 

172. Incus (enlarged) 414 

173. Stapes (enlarged) 415 

174. The Right Epitympanum and Antrum of a Child Two Years 

Old 4I5 

175. Adult Tympanum, Tegmen removed 416 

176. Under Surface of Right Temporal Bone 410 

177. Inner Surface of Right Temporal Bone 420 

178. The Foramina in the Fundus of the Left Internal Auditory 

Meatus of a Child at Birth. (±) Diagrammatic. 
(Morris) 421 

179. Diagram of Veins and Sinuses of Head and Neck, Left Side . 420 

180. Base of Skull, showing Venous Sinuses. Diagrammatic. . 427 

181. Section of Neck showing Topographical Position of Internal 

Jugular Vein 4 28 

182. Right and Left Labyrinth, Different Views 431 



XV111 LIST OF ILLUSTRATIONS. 



PAGE 



183. Left Membrana Tympani Secundaria 433 

184. Diagram of Membranous Labyrinth (Dearer) 434 

185. Diagram of Right Labyrinth, Viewed from Outer Side . . . . 435 

186. Microscopic Section of Xeuro-epithelial Structure of Macula 

Acustica Saculi 436 

187. Transverse Microscopic Section of Crista Acustica Utriculi . . 436 

188. Cross-section of Macerated Cochlea (enlarged) 437 

189. Cross-section of First Whorl of Cochlea (enlarged) 438 

190. Vertical Radial Section, Lamina Spiralis Ossea, Basilar 

Membrane and Papilla Acustica 439 

191. Diagram of Cochlear Nerve and Auditory Tract 440 

192. Vestibular Xerve and Tract 442 

193. Diagram of Xerve Connection about the Ear 445 

194. Outer View of Right Temporal Bone at Birth (enlarged) . . . 449 

195. Inner View of Left Temporal Bone at Birth (enlarged) . . .450 

196. Left Petromastoid Bone at Birth, Outer Side. The Squamo- 

tympanic Bone has been removed 450 

197. Vertical Section through the Meati, Anterior Half, Right 

Temporal Bone at Birth (enlarged) 451 

198. Same Bone as in Fig. 46, Posterior Half (enlarged) 452 

199. Vertical Section of Ear through Meati; Anterior Half, Left Ear, 

Infant 452 

200. Vertical Section of Ear, through Meati, Posterior Half, Left 

Ear, Infant 453 

201. External View of Right Temporal Bone of Infant One Year 

Old 454 

202. Temporal Bone at the Sixth Year (Morris) 455 

203. Sound Waves 464 

204. The Diagrammatic Curve of a Discord 466 

205. Diagram shewing Acoustic Balance, and Axis of Motion of 

Ossicles 469 

206. Characteristic Appearance of Aspergilli showing Spores and 

Fibres (magnified) . 487 

207. Diagram showing Forehead Mirror, etc 497 

208. Inserting Speculum in Right Ear 498 

209. Inserting Speculum in Left Ear 499 

210. A Right Drum Membrane extended and a Left Drum Mem- 

brane retracted 502 

211. Tympanic Membrane under Different Conditions 504 

212. Microtia and Polyotia of the Left Ear 514 

213. Patient with Mastoiditis 554 

214. Adjustment of Towels about Operative Field 567 



LIST OF ILLUSTRATIONS. XIX 



PAGE 



215. Outer Surface of Right Temporal Bone 568 

216. Commencement of a Mastoid Operation 569 

217. Complete Mastoid Operation 570 

218. Same Bone. Author's Modified Radical Mastoid Operation. 571 

219. Same Bone after the Performance of the Radical Mastoid 

Operation 572 

220. Diagram of a Mastoid Operation when the Bone Involvement 

requires Exposure of the Sigmoid Sinus or the Middle 
Fossa of the Skull 573 

221. Same Bone as Fig. 214. After Radical Mastoid Operation. . 574 

222. Same Bone. After Radical Mastoid Operation has been per- 

formed 575 

223. Incision for Plastic Flap of Meatus 576 

224. Application of Mastoid Bandage 578 

225. Lumbar Puncture 579 

226. Second Stage of the Auditory Nerve Resection Operation. . . 580 

227. Third Stage of the Resection of the Auditory Nerve 581 

228. Compression Splint for Othematomata 584 

229. Special Otological Instruments 597 

230. Three-ounce Glass Piston Syringe 599 

231. Two-ounce Soft Rubber Ear Syringe 599 

232. Politzer Air-bag. Forehead Mirror. Siegel's Otoscope. 

Ear Tip for Otoscope 600 

233. Politzer Bag 601 

234. Author's Surgical Electric Engine, held in the hand ready for 

use 601 

235. Galton's Whistle 602 

236. Politzerization 603 

237. Introduction of Catheter. First motion 604 

238. Introduction of Catheter. Second motion 605 

239. Introduction of Catheter. Third motion 606 



DISEASES OF THE NOSE, 
THROAT AND EAR. 



THE NOSE. 



CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE NASAL PASSAGES. METHODS OF 
EXAMINATION. INSTRUMENTS AND APPARATUS. 

ANATOMY. 

The nasal cavities are separated by a median partition, the septum, 
composed in front of cartilage and above and behind of bone — the 
perpendicular plate of the ethmoid, or mesethmoid, and the vomer. 
The shape and dimensions of the cartilaginous septum influence 
greatly the contour of the nose and the facial expression. This car- 
tilage is quadrangular, its anterior margin forming the outline of the 
nose, and being joined in front to the lateral cartilages, which to- 
gether form the alae and tip of the nose. The nasal bones and the 
nasal processes of the superior maxillae complete the framework 
of the external nose. The septal cartilage articulates above and 
behind with the anterior margin of the perpendicular plate of the 
ethmoid, below with the vomer and the bony ridge formed by the 
junction of the palatine processes of the superior maxillae. We 
rarely, if ever, find the cartilaginous partition between the nostrils 
exactly vertical for two reasons. The prominence of the nose renders 
it particularly liable to blows and injuries, and the development of the 
cartilage frequently progresses long after the bones of the face have 
become consolidated, hence a bending or distortion of the cartilage 
results. In consequence we meet with a great variety of deformities 
of the cartilage which will be more fully considered elsewhere. 

The posterior portion of the septum, being composed of bone and 
occupying a more protected situation, is relatively exempt from 
violence, so that we but seldom observe any displacement or asym- 
metry of the posterior margin of the vomer, no matter what degree 
of distortion of the septal cartilage may be present (Fig. i). 



2 DISEASES OF THE NOSE, THROAT AND EAR. 

The lateral cartilages are four in number, two on each side. Of 
these the lower have their anterior margins sharply recurved at their 
line of junction to complete the formation of the nasal septum, the 
partition between the anterior nares being called the columna nasi. 
The nasal fossae extend from the nostrils or anterior nares in front 
to the posterior nares or choanae behind and from the base of the 




J 

Fig. i. — The Nasal Septum. (Deaver.) 
a, Perpendicular plate of ethmoid; b, sphenoidal sinus; c, inferior lateral cartilage; 
d, septal cartilage; e, groove for nasopalatine nerve; /, vomer. 

skull to the hard palate. They are wider below than above and are 
almost never symmetrical, owing to deformities of the septum or 
turbinate bodies. 



ANATOMY OF THE NASAL FOSS.E. 



On the outer wall of each nasal fossa may be found the nasal proc- 
ess and the inner surface of the maxillary bone, the lachrymal, the 
ethmoid, the palate, the inferior turbinate bones, and the internal 
pterygoid plate of the sphenoid. The roof of the fossa is bounded 
by the nasal bone, the nasal spine of the frontal, the cribriform plate 
of the ethmoid and the body of the sphenoid. The floor of the naris 




Fig. 2. — Outer Wall of Nasal Fossa, with Mouth, Pharynx and Larynx in Vertical 

Section. (Deaver.) 
a, Superior meatus; b, superior turbinate body; c, middle turbinate; d y inferior tur- 
binate; e, inferior meatus; g, tongue; k, posterior pillar of fauces; i, geniohyoglossus 
muscle; j, geniohyoid muscle; k, hyoid bone; /, mylohyoid muscle; m, thyrohyoid mem- 
brane; n, ventricle of larynx; o, thyroid cartilage; p, diaphragma sellae; q. cavum so Ike-: 
r, sphenoidal sinus; s, middle meatus; t, rhinopharynx; it, Eustachian orifice; v, hard 
palate; w, soft palate; x, uvula; y, anterior pillar of fauces; z, tonsillar fossa; dd, oro- 
pharynx; bb, epiglottis; cc, aryepiglottic fold; </</, laryngopharynx: <v, suprarima! por- 
tion of larynx; ff, ventricular band; gg, vocal band; ////, infrarimal portion of larynx; .'.'. 
cricoid cartilage; jj, tracheal ring. 

is formed by the horizontal plates of the superior maxillary and 
palate bones. Each nasal cavity is partially subdivided by horizontal 
projections from its outer wall, the turbinate bones, which vary in 



THROAT AND EAR. 

size and number in different individuals, and which with the soft 
tissues covering them constitute the turbinate bodies. They are fre- 
quently described as being "scroll-shaped." In other words, in the 
normal condition, their septal surface is convex and their under and 
outer surface is concave (Fig. 2). 

Of these, the inferior is the only independent bone. The middle 
and superior are really processes of the ethmoid, as is likewise the 
fourth turbinate, or concha suprema, which is said to exist in about 
one in three or four specimens. The superior turbinate is practically 
a subdivision of the middle, with which it merges anteriorly. The 
turbinate bodies are of great interest and importance from a patho- 
logical as well as a physiological standpoint not only in themselves, 
but from the relation they bear to adjacent parts. 

The inferior meatus is that portion of the nasal passage lying 
beneath the inferior turbinate body and has opening into it the nasal 
duct which conveys secretion from the lachrymal sac. The duct 
itself is half to three-quarters of an inch long and runs downward, 
backward and outward. Its nasal orifice, near the anterior end 
of the turbinate body, is protected by a fold of mucous membrane 
called the valve of Hasner. This membranous valve ordinarily 
prevents distention of the lachrymal sac, as by air in the act of blow- 
ing the nose, but recent observations have shown that fluids may 
pass through it from the nasal cavity. Several other valvular folds 
of mucous membrane in the course of the duct have been described. 

Above the inferior turbinate and below the middle lies the region 
known as the middle meatus, into which open the passages from 
the antrum of Highmore, the frontal sinus, and the anterior ethmoidal 
cells. The most anterior is that of the frontal sinus, near the superior 
extremity of a crescentic furrow in the wall of the meatus known as 
the hiatus semilunaris, and usually just behind it is that of the eth- 
moidal cells. This part of the meatus including the orifices of the 
ethmoidal cells and of the frontal sinus is called the infundibulum. 
Sometimes the antrum, or maxillary sinus, has two openings. 

The hiatus semilunaris runs obliquely downward and backward 
from near the anterior end of the middle turbinate, and lies below 
the bulla ethmoidalis , an expanded ethmoid cell which projects into 
the meatus. The unciform process of the ethmoid, a thin plate of 
bone which articulates with the superior maxilla and with the in- 
ferior turbinate, and which enters into the formation of the nasal 



ANATOMY OF THE NASAL FOSS^. 5 

wall of the antrum, forms the lower boundary of the hiatus semi- 
lunaris. The ostium maxillare, the larger and more constant orifice 
of the antrum, is situated at about the middle of the hiatus. 

The space above the middle turbinate is called the superior meatus, 
into which open the posterior ethmoidal cells and the sphenoidal 
sinus. The orifice of the spheno-palatine foramen, covered by 
mucous membrane, is just above the posterior end of the middle 
turbinate body. At the line of articulation of the ethmoid with the 
nasal process of the superior maxilla near the anterior end of the 
middle turbinate appears a prominence on the outer wall of the 
fossa which has been described as the agger nasi. That portion of 
the fossa included by cartilage is called the vestibule of the naris, 
and is the only dilatable part of the passage, a point to be remem- 
bered in using the nasal speculum. The mobility of the alae of the 
nose, which is very highly developed in some of the lower animals, 
is provided for by the insertion of a number of sesamoid and acces- 
sory cartilages between the lateral cartilages and the nasal processes 
of the superior maxillae. To these, as well as to the cellular tissue at 
the margin of the nostril, muscular fibers are attached. 

Two other points of interest in the septum should be referred to, 
the organ of Jacobson, which exists in man in the form of a cul-de- 
sac just within the nostril and above the floor of the nose, and the 
tubercle of Morgagni, or Zuckerkandl, a spindle-shaped aggregation 
of glandular tissue opposite the anterior end of the middle turbinate 
body, at the line of junction of the cartilage and the perpendicular 
plate. It has been suggested that the former may bear an im- 
portant relation to perforations of the septal cartilage, which are 
frequently met with quite independently of syphilis, or other con- 
stitutional taint, while the latter when present in unusual volume 
may readily be mistaken for a pathological condition. 

The floor of the nasal cavity is not flat, but slopes slightly down- 
ward and backward and is concave from side to side. The crest 
of the maxilla forms a considerable eminence just within the nostril, 
and behind it close to the septum is a shallow cul-de-sac indicating 
the situation of the duct of Stenson, which is marked in the mouth 
by the incisive papilla. The position of the anterior palatine canal, 
of which the duct is a subdivision, is important. Here the artery 
of the septum from the sphenopalatine, the terminal branch of the 
internal maxillary, anastomoses with the anterior palatine artery 



6 DISEASES OF THE NOSE, THROAT AND EAR. 

from the descending palatine. Erosion or rupture of this arterial 
twig at the angle formed by the septum and the floor of the nose is 
a frequent source of epistaxis. 

The pituitary membrane lining the nasal cavities, known as the 
Schneiderian membrane, is continuous with that of the accessory 
sinuses, with that of the orbits through the nasal ducts, and with 
that of the tympani through the Eustachian tubes. It is much 
thicker and more vascular over the lower part of the septum and the 
turbinate bones, especially the inferior, than elsewhere. The transi- 
tion from integument to mucous membrane is very gradual. In the 
vestibule the mucous lining shows numerous vascular papillae and is 
covered with squamous epithelium. Just at the nostril are a number 
of short hairs or vibrissas which are intended to filter the inspired 
air. The epithelium of what is generally considered the respiratory 
region of the nose, or that part below the plane of the middle turbi- 
nate body, is columnar ciliated. The columnar epithelium lining 
the olfactory tract is not ciliated. The muciparous glands are 
tubular and of unusual length, extending through the entire thickness 
of membrane. In the olfactory region, besides the muciparous 
glands, we find tubular glands lined with round epithelium containing 
pigment, called Bowman's glands. 

The direction of the inspiratory current is influenced by the shape 
and position of the nostrils and by the vigor of the act of breathing. 
Recent experiments indicate that even in quiet inspiration the air 
current does not pass directly backward along the floor of the 
nose, but describes an upward curve and passes more or less over 
the middle turbinate body. In expiration it is supposed to be de- 
flected abruptly from the vault of the pharynx and pass out at a 
lower level. 

The nerve of special sense of smell, the olfactory nerve, reaches 
the upper part of the nasal cavity through perforations in the cribri- 
form plate of the ethmoid. It is distributed to the roof of the nose, 
to the superior and middle turbinate bodies and to the opposite sur- 
face of the septum. The terminal filaments of this nerve, just before 
reaching the surface of the mucous membrane between the epithelial 
cells, present fusiform expansions called the olfactory cells of 
Schultze. The subdivisions of the olfactory nerve, upward of 
twenty in number on each side, are invested with a coat from the dura 
mater and are said to differ from other cranial nerves in containing 



ANATOMY OF THE NASAL FOSS^. 7 

no white substance of Schwann and in having axis-cylinders with a 
distinct nucleated sheath which presents few and separated nuclei. 

The sensory nerves of the mucous membrane are derived from the 
fifth pair. Filaments from the external division of the nasal branch 
of the ophthalmic and from the Vidian supply the roof. The outer 
wall receives filaments from the superior nasal branches of the 
spheno-palatine ganglion, from the nasal, from the inner branch of 
the anterior dental and from the inferior nasal branches of the large 
palatine nerve. The septal branch of the nasal nerve, nasal branches 
of the spheno-palatine ganglion, the naso-palatine, and the Vidian 
are distributed to the septum. The floor is supplied by the naso- 
palatine and the inferior nasal branches of the large palatine nerve. 

The arteries of the nasal cavities are derived from the anterior 
and posterior ethmoidal branches of the ophthalmic, which supply 
the roof of the nose, the anterior and posterior ethmoidal cells and the 
frontal sinuses; from the nasal artery of the internal maxillary, 
which supplies the septum, the meatuses, and the turbinate bodies; 
from the posterior dental branch of the internal maxillary, which 
supplies the antrum (Holden). The veins, which accompany the 
arteries, communicate with the intracranial veins through the fora- 
mina in the cribriform plate, as well as through the ophthalmic vein 
and the cavernous sinus. 

The mucous membrane covering the turbinate bones has a peculiar 
structure demanding special description. Its spongy character has 
long been recognised, and fifty years ago Cruveilhier defined it as 
true erectile tissue. Later Kohlrausch, Bigelow and others made 
careful anatomical studies of this tissue, and still more recently the 
exhaustive investigation of Zuckerkandl established the existence of 
so-called "turbinated corpora cavernosa." It seems that the deep 
layer of the mucous membrane forms the periosteum. Distributed 
freely through the connective tissue of the membrane are lymph 
tissue and tubular mucous glands of extraordinary length. Within 
the lymphoid tissue are numerous venous sinuses surrounded by an 
abundance of unstriped muscular fiber. The "erectile tissue" thus 
constituted is subject to rapid and extreme variations in its dimensions 
under the influence of atmospheric conditions and of mechanical 
irritation, as well as of mental emotions. In dry air these bodies 
retract, in a humid air they swell. When this process o\ retraction 
and expansion has been too frequently repeated a condition of vaso 



8 

motor paresis becomes established, which results in more or less 
permanent enlargement of the turbinate body, with consequent nasal 
stenosis. This is the first stage of what will later be described as 
hypertrophy. 

The accessory sinuses, which are supposed to contribute to the res- 
onance of the voice, to diminish the weight of the skull and to 
afford protection to the nerve centers, are four in number on either 
side; the maxillary sinus, or antrum of Highmore, the frontal sinus, 
the ethmoidal sinuses, usually called cells, and the sphenoidal sinus. 
Of these, the largest is the maxillary sinus, which is a cavity in the 
superior maxilla bounded above by the floor of the orbit, within by 
the outer wall of the nasal fossa, and below by the roof of the 
mouth, its floor therefore being considerably below its normal outlet, 
which is found in the middle meatus. The frontal sinus lies between 
the tables of the frontal bone, the roof of the orbit forming its 
floor. A more or less complete median partition usually separates 
the frontal sinus into two parts. It also opens into the middle meatus 
near the orifice of the anterior ethmoidal cells. The sphenoidal sin- 
uses are two excavations in the body of the sphenoid bone sometimes 
divided by a vertical septum, but frequently communicating so as to 
form a single cavity. The ethmoidal cells, as their name denotes, 
are multiple cavities in the body of the ethmoid, separated by thin 
bony plates and arranged in two groups, anterior and posterior, the 
former opening into the middle, the latter into the superior meatus. 
The nasal orifices of the maxillary and frontal sinuses, and of the 
anterior ethmoidal cells, are in close proximity, and it has been 
shown that secretions from the frontal sinus may drain into the 
antrum and give many of the symptoms of antral disease. The 
clinical importance of this fact is very great, since opening the 
maxillary sinus under such circumstances would of course be en- 
tirely futile. Not infrequently the posterior ethmoidal cells open 
into the sphenoidal sinus, and the latter sometimes communicates 
with the antrum. The anatomical relations of the accessory cavi- 
ties and the variations from their normal arrangement are thus seen 
to be sources of difficulty in positively identifying sinus disease. 

PHYSIOLOGY. 

The nose is the organ of the special sense of smell, but its more 
important duties relate to the acts of respiration and phonation, it 



PHYSIOLOGY OF THE NOSE. 9 

being so constructed as to warm, moisten and filter the inspired air. 
We may remain in comparative comfort without the ability to detect 
odors, but complete, or even partial, stenosis of the nostrils is a serious 
impediment to health. It is merely necessary to cite the familiar 
example of an individual with "a cold in the head" to indicate the 
importance of unobstructed nasal passages to the production of a 
clear and resonant voice. Olfaction, respiration and phonation are 
therefore all more or less affected by morbid conditions in the nasal 
chambers. 

The sense of smell resides in the upper part of the nasal cavity, 
the olfactory nerve being distributed as low down as the middle 
of the middle turbinate body and the opposite surface of the septum. 
It is essential that odoriferous particles should reach this region, 
that the mucous membrane should be healthy, and that the nerve 
supply should be unimpaired. Otherwise the sense of smell may be 
lost, a condition known as anosmia. An interesting perversion of 
the sense of smell, the subjects of which perceive an odor not present, 
is called parosmia, and is undoubtedly a neurosis. It is some- 
times regarded as a precursor of mental alienation. Precisely how 
odors are appreciated is a matter of theory. Mechanical irrita- 
tion of the nerve filaments in the pituitary membrane, oxidation of 
odoriferous particles, molecular vibration, the heat-absorbing power 
of different materials, and finally the pigment-secreting quality of 
Bowman's glands have all been suggested in explanation of the 
function. A theory of the sense of smell recently propounded 
maintains that it is not due to contact of odoriferous particles with 
the nasal membranes, but to rays analogous to those of light, heat 
and the Roentgen-ray (Vaschide and v. Melle). The important 
degree to which the sense of smell contributes to our pleasure may 
be realized when we recall the limitations of the sense of taste, all 
flavors, with the exception of acid, bitter, sweet and salt, being 
recognized only through the olfactory nerve. The keenness of 
this sense depends in part upon the extent of the olfactory membrane. 
For this reason, the turbinate bodies in some of the lower animals 
are extraordinary in shape and dimensions. It is also said that its 
acuteness may be developed by practice. 

The inhalation of air at an unsuitable temperature, of an excessive 
degree of dryness, or laden with impurities is a source of irritation 
to the lower air passages and sooner or later of disease. Numerous 



IO DISEASES OF THE NOSE, THROAT AND EAR. 

experiments have been made in order to determine the increase in 
temperature and saturation which the inspired air undergoes in its 
transit throngh the nasal passages. It has been demonstrated that 
by the time the air reaches the pharynx through a normal nose, 
whatever the degree of external cold, it has become almost or quite 
as warm as the blood, and at the same time has become saturated 
with moisture, however dry the atmosphere may be. The interest- 
ing fact has also been established that the nose supplies to the ex- 
pired air a small proportion of carbonic acid, estimated at about one- 
fiftieth part of that contributed by the lungs. An examination of 
an individual exposed to a dust-laden atmosphere is sufficient to 
satisfy one of the extent to which foreign bodies in the inspiratory 
current are detained in the nasal fossae. In view of its complex 
functions it is easy to understand the importance of a normal nose, 
not necessarily a nose with perfectly symmetrical turbinate bodies, 
or with a septum absolutely smooth and vertical, but one capable of 
conveying to the lungs an adequate supply of pure air of proper 
quality. 

The resonance and timbre of the voice are markedly influenced 
by the shape and size of the nasal cavities, and an agreeable quality 
is given it by the formation within the nasal chambers of those 
secondary vibrations to which has been given the name, "over- 
tones." 

An attempt has been made to draw conclusions as to the site of 
intra-nasal lesions from the varying impressions they produce upon 
the quality of the voice, but we find it impossible to go farther than 
to say that stenosis of the anterior nares merely diminishes the res- 
onance of nasal sounds, which is retained in a measure so long as 
the naso-pharynx remains normal. The so-called "dead voice" 
of the Condition known as adenoids in the vault of the pharynx is an 
example of absolute loss of resonance. 

EXAMINATION AND INSTRUMENTS. 

The first essential to satisfactory examination of the upper air- 
passages is a good light. Sunlight may be utilized by means of a 
system of mirrors, but is not always to be had, and for the sake of 
convenience we resort to artificial sources of illumination. A Ger- 
man student oil lamp, fitted with a Mackenzie condenser (Fig. 3), 



METHODS OF EXAMINATION. 



II 



answers the purpose, but the Argand gas burner is better. The 
electric light is at our service and various head lights (Fig. 4; and 
lamps for use within the condenser have been devised. One of the 
best lights proposed, up to the present time, is what is known as 
the improved Welsbach light, which consists of a gauze network, 
chemically prepared, and placed over the Argand flame. This 
network, or mantle, is rather delicate and must be handled care- 
fully, but when protected by a mica chimney and the bullseye 
condenser, will burn upward of 1,000 hours and gives a very beauti- 
ful white light. The mantel may be renewed at trifling cost, and 
the original outfit is inexpensive. Having secured a good light, 
we next seek to reflect it upon the parts to be examined. In the 




Fig. 3. — Mackenzie's 
Light Condenser. 



Fig. 4. — Kuttner's Electric Head Light. 



more elaborate apparatus, as Tobold's, the reflector is attached 
to the lamp. It will be found more convenient, however, to wear 
the reflector upon the forehead. A concave glass mirror, 3 1/2 
inches in diameter, with a focal distance of about 16 inches and 
framed in aluminum is attached to a Pomeroy forehead piece and 
held to the head by means of a band of leather or silk braid, an 
inch in width. It is very light, and worn indefinitely with com- 
fort, and is to be preferred for operative work and when one has 
a large number of patients to examine successively. 

In all examinations of the nose and throat let the source of light 
be on the right of the patient, so that the right hand of the ex- 
aminer, with which most of the manipulating is usually done, may 
not interfere. The examiner should sit facing his patient with his 



12 DISEASES OF THE NOSE, THROAT AND EAR. 

knees separated, one on either side of the patient's knees. The 
position advocated by some, with the knees of the examiner together 
and on one or the other side of the patient, may be a gain in elegance, 
but is a sacrifice of steadiness, a point of importance in operating. 
The head mirror should be worn over the left eye in such a way that 
both eyes are brought into service. After a little experience one 
knows instantly whether binocular vision is obtained. At first an 
easy way to settle the question is to close the right eye and if then the 
open. left eye looking through the aperture in the center of the head 
mirror includes the whole circle of light thrown at the focal distance 




Fig. 5. — Duplay's Nasal Speculum. 

by the reflector, one is sure of using both eyes. On very close 
inspection of points in the depths of the nasal fossae only one eye at 
a time can be used. It is well to have all the instruments to be 
brought in contact with the patient comfortably warmed. In the 
case of throat mirrors this is indispensable in order to obviate con- 
densation of moisture upon the glass. The mirror should be warmed 
by holding it face down, over the gas flame for a few seconds, and 
the degree of heat should be tested on the ball of the examiner's 
thumb before the mirror is placed in the throat. Nothing so unnerves 
a timorous patient, aside from general awkward management, as the 
touch of an excessively hot mirror. 

Inspection of the nasal and naso-pharyngeal cavities is called 
rhinoscopy. By anterior rhinoscopy we discover the condition of 
the cartilaginous septum, the floor of the nose, and the anterior 
ends of the middle and inferior turbinate bodies. This procedure 
is very much facilitated by preliminary spraying of the nares with 
a 4 per cent, solution of cocaine. The indiscriminate use of cocaine, 
however, should not be encouraged, and it never should be used 
until we have first seen the parts in the natural state. We study 



METHODS OF EXAMINATION. 



13 



the posterior nares and the naso-pharynx by means of small mirrors 
introduced into the oro-pharynx, or posterior rhinoscopy. 

A good nasal speculum in anterior rhinoscopy is almost as neces- 
sary as good illumination. The ideal speculum should be easy of 




Fig. 6. — Hartmann's Nasal Speculum. 

manipulation, give the patient no discomfort, and be capable of 
admitting a generous flood of light as with the Duplay speculum 
(Fig. 5). Its solid blades have the double advantage of exert- 
ing uniform diffuse pressure and pushing aside the vibrissas, 




Fig. 7. — Jarvis' Nasal Specula. 

which grow so profusely in the nostrils of some patients, and which 
are apt to protrude through the opening of a fenestrated speculum 
and impede the rays of light. Hartmann's speculum is also a 
very convenient instrument (Fig. 6). The walls of the nasal vesti- 



14 DISEASES OF THE NOSE, THROAT AND EAR. 

bule are but slightly dilatable, hence the importance of using a 
speculum the separation of whose blades may be regulated at will. 
All fenestrated instruments, with uncontrolled springs, are to be 
condemned. In operating far back in the nasal cavity the Jarvis 
speculum (Fig. 7) is more convenient, since it is lighter and self- 
retaining, and is less apt to get in the way of the operator. 

No rhinoscopic examination should be considered complete until 
inspection of the mucous membrane has been supplemented by pal- 



Fig. 8. — Jarvis Rhiriometer. 

pation with the probe. We thus gain information as to the vascu- 
larity, the density and mobility of the structures normal or morbid. 
It is also frequently important to determine the sensitiveness of 
the pituitary membrane, or to define areas of suspected hyper- 
esthesia. If still more exactness is desired, we may measure the 
width of the nasal passages at various points by means of Jarvis' 
rhinometer, or the thickness of the septum with Seller's septometer 




Seiler's Septometer. 



(Figs. 8 and 9). The roof of the nose and the region of the openings 
of the posterior ethmoidal cells and of the sphencidal sinus may 
be exposed by median rhinoscopy (Killian). The middle turbinate 
body can be pushed aside by means of a long-bladed speculum 
passed between it and the septum. The method is not very painful 
after the free use of cocaine and is of occasional service in determin- 
ing the source of suppuration in doubtful cases. 



METHODS OF EXAMINATION. 1 5 

In posterior rhinoscopy we frequently have to contend with various 
obstacles, such as a rebellious tongue which resents the pressure of 
the tongue spatula, an irritable pharynx whose muscles contract in 
the act of gagging almost as soon as the mouth is opened, an un- 
usually narrow space between the palate and the pharyngeal wall, 
or persistent elevation of the velum during an attempt to illuminate 
the posterior nares. In many cases we succeed in getting a view 
only by the exercise of the utmost tact and patience, and our 
subject may have to be put through a course of training for several 





Fig. 10. — Turck's Tongue 
Depressor. 



Fig. 11. — Bosworth's Tongue 
Depressor. 



weeks before giving more than a glimpse of the parts we wish 
to explore. The tongue should never be roughly handled. A 
Tiirck depressor with a smooth tongue piece, held in the examiner's 
left hand, should be applied to the middle of the dorsum of the 
tongue not too far back and steady, firm pressure made in a down- 
ward direction (Figs. 10 and n). The rhinoscopic mirror, Xo. i. 
or larger in trained subjects, properly warmed, is then introduced 
face upward to the right of and behind the inula, care being taken 
to avoid sudden and rough contact with the wall of the pharynx. 



1 6 DISEASES OF THE NOSE, THROAT AND EAR. 

The patient is directed to breathe quietly meanwhile through the 
nose. By gently raising or lowering the right hand which holds the 
mirror and by slightly rotating the shaft without shifting the mirror 
about in the fauces, the examiner will finally get all the details of the 
rhinoscopic image. It is rarely possible to use a mirror large enough 
to give a complete picture. 

Irritability of the pharynx may usually be overcome by frequent 
repetitions of examination from day to day. Attempts at the first 




' Fig. 12. — White's Palate Hook. 

sitting should be abandoned in case there is found to be extreme 
sensitiveness. We succeed in establishing tolerance by directing 
the patient to pass his forefinger far back upon the dorsum of 
the tongue and over the velum several times a day, thus accustoming 
the pharynx to the presence of a foreign body. The patient may 
hold small pieces of ice in the mouth for fifteen minutes before 
examination, or if the necessity is urgent, we may spray the pharynx 
with a four per cent, cocaine solution. Cocaine may defeat us 




Fig. 13. — Kyle's Postnasal Electric Lamp. 

by the nausea which it excites in certain individuals. It should 
be used for purposes of examination only as a last resort, and the 
patient should always be warned of the discomfort it is likely to 
cause. In some cases assistance is gained from the use of a palate 
hook by which the velum is held forward. One of the most conve- 
nient is White's (Fig. 12), which has been modified by dispensing 
with the joint in the shaft and adjusting a rubber band, so as 
to make the instrument automatic. For ordinary use it is not to 
be recommended, since we find that it is most easily applied in those 



METHODS OF EXAMINATION. 1 7 

tolerant throats which permit a satisfactory examination without it. 
Yet in certain rare cases of doubtful diagnosis, or in which the elec- 
tric cautery is to be used in the naso-pharynx, it is serviceable. 
After an application of cocaine it is borne without objection. 

A thickened or elongated uvula, or hypertrophied palatal tonsils 
add more or less to the difficulties of a posterior rhinoscopy, but 
they are seldom insurmountable. 

A small electric lamp fixed at a right angle to a suitable handle 
passed behind the velum gives an excellent illumination of the 
pharynx as well as of the nasal cavities. After the patient has 
learned to keep the lamp in place with the closed lips a good view 
is obtained by looking through the anterior nares. Such a lamp 
as that devised by Kyle (Fig. 13), which is protected by a movable 
aluminum cap, produces little or no discomfort by the evolution of 
heat. 

Digital examination of the naso-pharynx is a procedure too much 
neglected. It is by no means agreeable to the patient, but it is 
done quickly, and it is well for the student to familiarize himself 
with the landmarks of this region by the sense of touch. In young 
children, and in those who will not tolerate rhinoscopy, it is the only 
way by which a knowledge of the extent and disposition of lymphoid 
hypertrophies can be gained. In practising this method in young 
subjects the finger is protected by a jointed metal shield, or a piece 
of elastic rubber tubing, or the following course is adopted. The 
child is held in the lap of the mother, or of an assistant, who con- 
trols its hands. The examiner then standing on the child's left 
presses his right middle finger upon the patient's right cheek, at the 
same time bringing its head against his own body. The firm pres- 
sure causes the child to open its mouth, when at once the examiner's 
left forefinger should be passed into the pharynx. The pressure 
being maintained the cheek is pushed between the teeth of the open 
mouth, and the examining finger is safe, since the child cannot 
close its jaws without biting its own cheek. 



CHAPTER II. 

ACUTE AND CHRONIC RHINITIS. 

Inflammation of the mucous membrane lining the nasal passages, 
or rhinitis, may be acute or chronic. The phenomena of chronic 
rhinitis are so complex and its complications and consequences so 
varied as to demand extended description. 

The symptoms of acute rhinitis, or coryza, are familiar and need 
but little attention. The majority of people have a "cold in the 
head" from time to time, think it of slight consequence and let it 
run its course. It is certainly worth while, however, to consider the 
causes of "catching cold" and the measures adapted to its preven- 
tion and relief. In addition to individual proclivity based upon a 
diathetic condition, there are certain local structural changes and 
relations within the nasal fossae which make one particularly liable 
to catch cold. Moreover, we all recognize the fact that occupa- 
tions which involve exposure to frequent and abrupt changes of 
temperature or to irritating vapors increase the liability. The nerve 
theory of etiology is maintained by some. A neurotic element is no 
doubt often prominent and the predisposing influence of depressed 
general health is beyond question. It is undeniable that a general 
atmospheric state sometimes exists which leads to the development 
of a pandemic of acute rhinitis. Under such circumstances there is 
a natural suspicion of contagion, but as yet we have no positive proof 
that rhinitis is thus transmitted. Some of the causes immediate 
and remote are avoidable, and it is equally true that the course 
of the disease may be cut short by appropriate treatment. Many 
of the more serious and distressing chronic affections of the nose 
have their origin in a neglected cold in the head. 

Prophylaxis is a far more important function of the physician than 
drug giving. The question of ventilation, especially of sleeping- 
rooms, and the matter of quality and kind of underclothing are sub- 
jects by no means beneath his notice. They certainly have a most 
serious bearing upon the susceptibility of a patient to cold from ex- 
posure. We all know the danger of sudden chilling of the surface 

18 



ACUTE RHINITIS. IQ 

when overheated. We think less of the ill effects of superheated 
foul air in our homes and places of amusement. The use of cold 
water as a means of toughening the cutaneous surface is highly esti- 
mated and perhaps justly, but many of its enthusiastic advocates lose 
sight of the depressing effect it may have upon the general system. 
By judicious hints as to points of hygiene, dress and diet, it is doubt- 
less possible to prevent many of the catarrhal affections which are so 
difficult to cure. How far climatic influences are factors in the causa- 
tion of "catarrh" it is difficult to say. A similar observation is 
true of the tobacco and alcohol habits. It is not unusual to hear a 
patient say that he never has trouble except when he comes to New 
York, while the next visitor may remark that he is never so com- 
fortable elsewhere. One patient will affirm that tobacco and alcohol 
invariably aggravate his catarrhal symptoms, while the next, an in- 
veterate smoker, will express his belief that tobacco has preserved his 
health. It seems to be impossible to lay down an arbitrary rule on 
these points. They are matters of individual experience. In general 
it may be said that the excessive use of these luxuries is harmful. 
What constitutes excess depends upon temperament, occupation and 
general habits of life. Moderation in one may be excess in another. 
The relationship between sexual excitement and turgescence of the 
nasal erectile tissue is obvious and sexual excess must be included 
among the factors in the etiology of rhinitis. 

As to the propriety of the term "catarrhal diathesis," which is 
sometimes used to indicate a propensity to inflammation on the part 
of the mucous surfaces generally, it is reasonable to assume the ex- 
istence of a constitutional condition which influences the vital resist- 
ance and functional activity of the mucous membranes as well as of 
other tissues and organs of the body. 

In the first stage of an acute rhinitis, the mucous membrane is 
abnormally dry and the patient is conscious of some obstruction to 
nasal breathing. Sneezing, lachrymation, more or less frontal heavi- 
ness, or actual headache, with a feeling of general lassitude and de- 
pression, comprise the usual train of symptoms. If the inflammatory 
process actually extends to one or more of the accessory sinuses. 
which, fortunately, rarely happens, there is more decided pain. 
neuralgic in character. There is generally more or less congestion oi 
the sinuses associated with an acute rhinitis, and especially in the 
frontal region there may be complaint of sensitiveness and a feeling oi 



20 DISEASES OF THE NOSE, THROAT AND EAR. 

tension. The sense of smell is completely abolished for the time 
being. One of the most annoying symptoms is tinnitus aurium, 
frequently accompanied by impairment of hearing and a sense of 
fullness in the ears, dependent, no doubt, upon extension of the in- 
flammatory process to the naso-pharynx and the orifices of the 
Eustachian tubes. There may be a mild degree of pyrexia. In the 
course of a few hours the dryness of the membranes is succeeded by 
an effusion of watery secretion, more or less profuse, at first mucous 
and gradually becoming purulent. In the declining stage the dis- 
charges become thicker and dryer. If inspected in the prodromic 
stage the mucous membrane is seen to be excessively tumefied, 
dry and glazed, and very red. In the second stage the swelling and 
redness may persist, but the surfaces are bathed in mucus. In the 
final stage we find the congestion and swelling less, but the nasal pas- 
sages are apt to be obstructed by tenacious purulent and inspissated 
secretion. Usually in a week or ten days the patient is restored to 
health, but not without perceptible aggravation of a preexisting 
'abnormality, or certain changes in the tissues which increase the 
tendency to recurrent attacks. 

Treatment. — An attack of acute rhinitis may be invariably miti- 
gated and sometimes aborted. At the outset it is customary to 
give to an adult ten grains of quinine with ten grains of Dover's 
powder, and proportionate doses to children, unless there is some 
known contra-indication. By many this course is strongly op- 
posed. Measures tending to encourage perspiration are often 
used with benefit, such as the hot foot bath and hot lemonade inter- 
nally. Some observers insist upon entire abstention from fluids 
internally, with the result, it would seem, of adding rather to the 
patient's discomfort. On the other hand, Cohen recommends copi- 
ous draughts of water. The less local meddling the better, but there 
seems to be no doubt that an application of cocaine, two per cent, 
to the inflamed nares, followed by an insufflation of Ferrier's snuff 
(morph. sulph. gr. i, bismuth, subnitr. 5iii> pulv. acacia 50 is very 
soothing and contributes to the comfort of the patient (Fig. 14). 
Cocaine should never be entrusted to a patient except in extreme 
cases and unless we are quite sure of his capacity to resist the fasci- 
nations of the habit. The abuse of an agent, so energetic and decided 
in its action, may do permanent harm. There is no doubt about the 
comfort it gives by emptying the venous sinuses and thus restoring 



ACUTE RHINITIS. 



21 



the caliber of the nostrils, but its effects are transitory, and the 
temptation to resort to it again and again is almost irresistible. The 
promiscuous recommendation of cocaine is, therefore, dangerous and 
should be discountenanced. A solution of cocaine alkaloid, 2 per 
cent, in equal parts of almond and petroleum oil has been found by 
Wyatt Wingrave to give more prolonged results though acting some- 
what more slowly than a watery solution. A 5 per cent, watery 
solution of cocaine hydrochlorate, containing 2 per cent, sodium sul- 
phate, proved to give as complete effects as much stronger solutions of 
cocaine alone. Thus the danger of toxic symptoms is much reduced 




Fig. 14. — Universal Powder Blower. 

and moreover the combination is more rapid in its action. The 
inhalation of a vapor of camphor and menthol (5 grs. of each to one 
ounce of fluid albolene or benzoinated albolene) usually gives 
temporary relief and may be safely repeated at short intervals. The 
patient may be instructed to inhale from a wide-mouthed bottle con- 
taining equal parts of powdered camphor and menthol to which a 
few drops of ammonia have been added. The famous Hager-Brand 
remedy (acid, carbol. 5i> alcohol 5 hi, aq. amnion, fort 5*j a 4- dis- 
till. 5ii) is used in a similar way, or is sprinkled on a handkerchief 
and inhaled. Many drugs of this class are satisfactorily inhaled 
from a nebulizer or vaporizer (Fig. 15). 



2 2 DISEASES OF THE NOSE, THROAT AND EAR. 

A combination, the value of which has been somewhat exagger- 
ated, for controlling secretion and reducing the turgescence of the 
erectile tissue, is a tablet (rhinitis tablet) containing one-eighth of 
a minim of belladonna rl. ext. and one-fourth grain each of camphor 
and quin. sulph. to be given half hourly until ten or twelve have been 
taken or the patient becomes aware of a feeling of dryness in the 
pharynx. In malarial cases quinine is indicated. In rheumatic and 
gouty subjects the salicylates and antilithics are of service. In this 
connection it is of interest to note the alkaline treatment of a "cold 
in the head," as advocated by Bulkley. who gives bicarbonate of soda 
in full and frequent doses. The necessity of treating a rhinitis com- 
plicating the exanthemata in children by means of cleansing and 




Fig. 15. — The DeYilbiss Invertible Nebulizer. 

germicidal solutions should be appreciated. The relative importance 
of general symptoms sometimes leads to neglect of the local condi- 
tions with disastrous results. Space does not permit reference to 
numerous other remedies, local and general, most of them of indiffer- 
ent value, with the exception of adrenal extract, to be referred to 
in the section on hay fever, and of hourly insufflations of orthoform, 
either pure or combined with sodium sozoiodolate, as confidently 
recommended by Spiess. The use of the latter is based on the 
neuropathic theory of causation, and the applications are said to be 
more effective if made through the mouth to the vault of the pharynx. 
In conjunction with the local treatment various drugs classed as 
antineuralgics or nervines are given internally. 

In a small proportion of cases recovery from a course of acute 
rhinitis does not ensue and we have established a condition of chronic 
rhinitis, known to the public and to many general practitioners as 
" catarrh." 

For the sake of simplicity, we may divide chronic rhinitis into three 
varieties, catarrhal, hypertrophic and atrophic, basing this subdivi- 



CHRONIC RHINITIS. 23 

sion upon the clinical phenomena characteristic of each. Several 
other forms, comparatively rare and named from certain prominent 
symptoms, will be described. 

In chronic catarrhal rhinitis hypersecretion is the principal symp- 
tom. The patient soils many handkerchiefs during the day and is 
constantly annoyed by the accumulation of secretion in the postnasal 
space. Nasal respiration is not perceptibily impeded, or the patient 
may complain of intermittent stenosis alternating between the nos- 
trils. We have here, then, an early sequel of an acute process which 
involves mainly the glandular elements of the mucous membrane, 
but which will sooner or later develop structural changes of a hyper- 
plastic character. 

In the latter case, hypertrophic rhinitis supervenes, the main fea- 
ture of which is persistent continuous obstruction to nasal breathing. 
The secretions are still apparently in excess. As a matter of fact, 
their proportion is reduced, but their quality is so perverted and the 
changed conditions so prevent their normal disposition, that they 
accumulate in the nasal chambers until removed by violent efforts at 
expulsion. The attempts at clearing the pharynx, especially in the 
morning, are often very distressing. These patients are habitual 
mouth breathers and snorers, and are apt to waken from sleep in the 
morning with the mouth and tongue dry and parched. Disorders of 
digestion are not infrequent, attributed perhaps unjustly to putrid 
and decomposing secretions finding their way from the pharynx to 
the stomach. The larynx may be affected and the voice becomes 
hoarse in consequence of the inspiration of improperly prepared air, 
the function of the nose being entirely or in part suspended. Among 
the more annoying, and at times painful symptoms of hypertrophic 
rhinitis, may be mentioned various reflex disturbances resulting from 
intranasal pressure. This subject has been actively investigated in 
recent years and many interesting phenomena have been discovered. 
It has been clearly demonstrated that very many functional disorders 
of the eye and notably of the ear are due to a point of irritation 
or pressure within the nose. Facial neuralgia, frontal headache. 
cough and derangements of the voice may be attributable to a similar 
cause. The relief to ear symptoms following intranasal operations 
is sometimes very striking. Unfortunately, in many cases the aural 
difficulty has passed the line of purely functional disturbance before 
a nasal lesion is sought for or suspected. While it must be admitted 



24 



DISEASES OF THE NOSE, THROAT AND EAR. 



that chronic turgescence of the turbinate erectile tissue and other 
nasal lesions may induce changes in the function and structure of 
various organs, we must avoid the error of assuming that all 
human ills have a nasal origin. 

It is difficult to fix a line which separates the varieties of chronic 
rhinitis. The pathological processes merge into each other by such 
slow gradations that we frequently find several of them represented 
in the same subject. One nostril may be blocked by hyperplasia, 
while the other is widely expanded in an advanced stage of atrophy. 

The diagnosis of an established case of atrophic rhinitis is usually 
easy, but the difficulty of identifying the two varieties of chronic 





Fig. 16. — Lobulated Hyperplasia of Left Inferior and Right Middle Turbinate. 

(Griinwald.) 



rhinitis which have been described is greater. We rely upon in- 
spection, touch with the probe and cocaine to differentiate them. 

The first (hyperemia) presents a red tumefaction of the turbinate 
bodies, of uniform smoothness, which is quite sensitive and bleeds 
freely. It yields to compression with a probe, and in the early 
stages the pressure being released the tumor instantly reforms, 
owing .to reengorgement of the erectile tissue. Later on when 
vasomotor paresis occurs the furrow caused by the probe is more 
lasting. The swelling promptly subsides under cocaine. In the 
second form (hyperplasia) the tumor is paler in color, irregular in 
contour, and less sensitive and vascular. Frequently, it is distinctly 
lobulated, papillated, or even fimbriated (Fig. 16). It is mani- 
festly more dense in structure, is compressed only by very firm 
pressure with the probe, and resumes its original shape very slug- 



CHRONIC RHINITIS. 25 

gishly. It does not completely shrink after an application of 
cocaine. 

In deciding upon a course of treatment it is important that we 
should distinguish these conditions. In the former case, sedative 
applications, mild astringents perhaps, and the correction of vicious 
habits, notably the pernicious practice of violent nose blowing, will 
suffice. In the latter we have to deal practically with a foreign 
body which must be removed. 

Vasomotor paresis of the walls of the blood-vessels composing 
the erectile tissue of the turbinate bodies is a prominent feature of 
the transition stage of hypertrophy. A physiological process thus 
gradually becomes pathological and the muscular walls of the venous 
sinuses undergo degeneration in consequence of which they remain 
permanently dilated until compressed and obliterated by the sur- 
rounding new connective tissue. This constitutes what is some- 
times described as a "turbinal varix," seen usually at the posterior 
end and lower border of the inferior turbinate. Not infrequently, 
the osseous structures themselves become implicated in the inflam- 
matory process, or undergo enlargement as a result of hypernutrition. 
A most interesting series of pathological changes ensues involving 
chiefly the middle turbinate bone, which until recently has received 
but little attention. The bone may be simply thickened, or it may 
undergo a process of cystic formation or expansion. The inferior 
turbinate is but seldom thus affected, whereas in the case of the 
middle turbinate the discovery of these osseous cysts is a common 
occurrence. Their development is explained in various ways. In 
the majority of cases it doubtless results from a rarefying osteitis 
inducing absorption of the interior of the body of the bone. In 
other cases the cyst is believed to be due to the prolongation of an 
ethmoid cell into the body of the middle turbinate and its subsequent 
expansion. 

The developmental theory of etiology is accepted by Payson 
Clark, who professes to have found no evidences of inflammatory 
action in four cases of concha bullosa operated upon by himself, and 
who has discovered in literature only four cases accompanied by pus 
formation. On the other hand J. Wright points out the presence of 
osteoblasts building up bone on the outside of these cysts while 
osteoclasts are absorbing it within. Thus a preexisting cavity be- 
comes larger and larger as a result of a low grade of osteitis. These 



26 



DISEASES OF THE NOSE, THROAT AXD EAR. 



cysts are very common, Zuckerkandl having found them thirty-six 
times in 200 post-mortem observations. They are generally met 
with in adults and are more frequent in women than in men. 

The cyst sometimes reaches enormous dimensions, as shown in 
the accompanying plate (Fig. 17). The mucous membrane covering 
it may persist in its hyperplastic condition, may become polypoid, or 
may atrophy. It is perhaps more usual to End it in the last men- 
tioned state. The tumor might readily be mistaken for a polyp or 
an ordinary hypertrophy unless carefully examined with a probe, 
when its hardness and immobility are detected. Often the bony 




Fig. 



-Cyst of Middle Turbinate Bone. (Author's specimen.) a, Nasal surface; 
b, interior of cyst. 



shell forming the wall of the cyst is so thin as to be readily punctured 
with a sharp probe (Fig. 18). 

Treatment. — In the early stages of chronic rhinitis we should en- 
deavor to soothe the irritated mucous membrane and to reestablish 
its normal functional activity. The warning against hasty and too 
free use of destructive agents at this period cannot be repeated often 
enough. In our clinics many patients are met with who can dis- 
tinctly trace their condition of incurable atrophy to excessive zeal in 
the use of caustics. Some, at least, of these might have been saved 
by mild measures, and by attention to the general health and mode 
of life. It may prove to be necessary to cauterize, but before doing 
so in any case in which we cannot clearly define areas of hyperplasia, 



CHRONIC RHINITIS. 



2 7 



we should see what may be accomplished by diligent use of alkaline 
and antiseptic sprays or douches. Fluid applications may be made 
to the nares by means of an atomizer (Fig. 19), or of one of the 
various nasal douches (Fig. 20), cups or syringes (Fig. 21). The 
spray tubes made of very thick glass, in one piece, and with blunt 
tips, are entirely satisfactory (Fig. 22). Three styles are needed, up, 
down, and straight. The first two should be five inches in length, 




Fig. 18. — Section of Bony Cyst of Middle Turbinate. (Author's specimen.) 

a, Layer of stratified epithelium; b. layer of richly cellular vascular connective 
tissue, which is rather more dense about the lamina? of bone, c-c-d; e, layer of very 
loosely arranged edematous connective tissue resembling myxomatous tissue; /, layer 
of ciliated epithelium; g, layer of osteoblasts. 



the last need not be more than three or four inches from the angle 
to the tip. The t)eVilbiss spray tubes, made of metal, are more 
durable, and having a movable tip will throw the spray in any 
direction desired. A hand ball, or one of the compressed air ap- 
paratus, according to convenience, may be used to form the spray. 
The pressure on the latter should not exceed twelve pounds, and 
often one-half that degree of force will be ample, except with the 
heavier oily sprays. 



25 DISEASES OF THE NOSE., THROAT AND EAR. 

One of the best known solutions intended for use in this way is 
DobelFs solution (acid, carbolici gr. iv-x, sodae boratis, sodae bicarb, 
aa gr. xl, glycerin 5i y j aquae ad §iv). The famous Seiler tablet is 
quite as familiar to the laity as it is to the profession and in solution 
of proper strength is agreeable and satisfactory. x\n excellent 




Fig. 19. — Lefferts' Hand Atomizer. 



solvent for viscid secretion is warm salt water, in other words 
physiological or normal salt solution. In the majority of cases 
marked results will be obtained from menthol dissolved in fluid 
albolene (gr. ii-v to 51). i\lthough oil and water will not mix and 
we cannot expect the mucous secretions and the albolene solutions 
to violate this law by showing an affinity for each other, yet we find 




Fig. 



-Woakes' Xasal Irrigator. 



Fig. 21. — Xasal Syringe. 



that oily solutions serve a threefold purpose. They ensure gradual 
and prolonged action of the medicament which they may hold in 
solution or suspension, they prevent the incrustation of secretion which 
is a more annoying feature of later phases of chronic rhinitis, and they 
furnish a protective film to the hypersensitive mucosa. It is true 



CHRONIC RHINITIS. 20. 

that sprays alone will not cure catarrhal conditions; it is true that 
oily solutions are disagreeable to some patients and act unfavorably 
upon some mucous membranes; but the fact remains that the spray, 
properly used, is a valuable and an elegant agent for cleansing and 
medicating the upper air-passages, the larynx, and pharynx, as well 
as the nasal cavities. It hardly need be said that medicated applica- 
tions should be preceded by thorough cleansing of the surfaces 
especially in atrophic rhinitis when the nares are stuffed with 
hard and dry secretions. One of the best detergent solutions in 
common use is warm salt water, one teaspoonful of table salt to a 
pint. It is important to observe this proportion and all lotions to be 



Fig. 22. — Sass' Glass Spray Tubes. 

used in volume from a cup, douche, or syringe are more agreeable 
and more effective if applied warm. Heating the spray mixture is 
less important since the temperature of atomized fluids falls almost 
instantly, but in cold weather the oils and heavy solutions may be 
sprayed more readily if previously warmed. Astringents to control 
hypersecretion seem to be indicated, yet we find that drugs of this 
class are sometimes worse than useless, since the Schneiderian 
membrane often exhibits more or less intolerance of their action. 
The discomfort of the patient is sometimes increased, their effect in 
checking secretion is very transient, and the sense of smell is in 
danger of being impaired by too vigorous and too frequent applica- 
tions. The use of powders of various kinds has been popular at 
times, but they offer no advantage over drugs already in solution 
and are decidedly irritating unless great care is taken in their prep- 
aration. The least objectionable is a powder of stearate of zinc 
with boric acid which combines mild astringent with sedative and 
antiseptic properties and in certain cases seems to act favorably. 



30 DISEASES OF THE NOSE, THROAT AND EAR. 

Stearate of zinc is an excellent vehicle for other powders, such as 
aristol, europhen and iodol. It seems irrational, however, to ask 
the secretion of an inflamed mucous membrane to act as a solvent 
for these drugs, when the solution may be made more rapidly and 
accurately before their introduction to the nasal chambers. The 
value of the so-called antiseptics is, to say the least, doubtful. A 
solution strong enough to kill pathogenic germs must at the same 
time destroy the tissues. 

The treatment of rhinitis at this period, therefore, consists mainly 
in the correction of bad habits, the regulation of diet, and the 
restriction of local measures to the use of remedies which tend to 
reduce congestion and to restore the normal function of the secretory 
glands. 

When the chronic catarrhal process has advanced to the second 
stage we are confronted by a totally different condition. Here 
certain structural changes have taken place in the mucosa which 
lead to permanent narrowing of the nasal passages and which can be 
relieved only by surgical intervention. The method to be selected 
depends largely upon the particular region affected. If nasal 
respiration is seriously interfered with, if nasal drainage is impeded, 
if neuralgia or other reflex phenomena can be traced to a point of 
contact or pressure within the nasal fossae, or if the sense of smell is 
impaired by an obstructive overgrowth, the indications for surgical 
interference are sufficiently clear. We rarely, if ever, meet with a 
lesion of this kind involving only the sense of smell. We may have 
reflex disorders or imperfect drainage, due to pressure, without 
respiratory stenosis. A lesion which prevents breathing through 
the nose cannot exist without interfering with drainage and generally 
weakens the sense of smell and provokes more or less reflex dis- 
turbance. Other considerations which should influence our choice 
of a mode of operating are the age of the patient, the duration of his 
difficulty and the temperament of the individual. In general the 
older and denser the hyperplasia the more energetic should be our 
attack upon it, but in children and in nervous subjects we may be 
forced to reject formidable apparatus and active agents for more 
tedious and less disturbing methods. Moreover, we must take care 
to avoid a violence in dealing with the middle turbinate body and the 
roof of the nasal chamber which may be exercised with impunity in 
the case of the inferior turbinate and the floor of the nose. If our 



CHRONIC RHINITIS. 3 I 

patient is known to be a bleeder or if there is a reason for wishing to 
avoid even moderate depletion, one of the bloodless methods of 
operating is preferable. 

Hyperplastic tissue must be looked upon as a foreign body. There 
is no possibility of wholly restoring a mucous membrane thus 
affected. Until, therefore, the overgrowth is removed or reduced 
by surgical measures or by the slower natural process of atrophy, we 
cannot reasonably expect any substantial relief of symptoms. The 
majority of these patients have tried the various advertised nostrums 
for "catarrh," or at least, have been in the habit of snuffing up salt 
water, before they apply for special treatment, and they may be 
considered fortunate if they have escaped troublesome complications, 
especially in the form of inflammation of the middle ear. Patients 




E. B. MEYROWlTZ, N. Y. 

Fig. 23. — Jarvis' Cold Wire Snare. 

should be invariably cautioned against violently blowing the nose, 
especially with compressed nostrils, after the use of a nasal wash or 
douche. Excessive nose blowing which many with hypertrophic 
rhinitis practise is damaging to the intranasal tissues as well as to the 
ears. In washing out the nostrils the stream of fluid should always 
be thrown in by the narrower nostril, so that the return current may 
find unobstructed exit by the other nostril. 

There are three satisfactory ways of disposing of hyperplasia of 
the soft tissues of the nares: (a) By cutting operations with the 
cold wire snare, scissors, or forceps, (b) the electric cautery, and (c) 
chemical caustics. 

The cold wire snare is best adapted to extreme cases in which the 
soft tissues protrude into the nasal passage to such a degree as to 
allow the wire loop to be well embedded (Fig. 23). If the surface 
of the hypertrophy is smooth and shades off into the adjacent pans 
it is very difficult to include the desired amount of tissue within the 
loop. To obviate this objection, Jarvis advises preliminary trans- 
fixion of the mass to be snared, the loop being then adjusted over the 
ends of the transfixion needle. Practically we find that this leads 
to cutting out a furrow along the track of the needle, if a single 
needle be used, and if several needles are applied the operation 



3 2 



DISEASES OF THE NOSE, THROAT AND EAR. 



becomes unnecessarily complicated. It is a good rule, therefore, 
to use the electric cautery for those cases in which the loop cannot 
be employed without the aid of transfixion needles. An ingenious 
suggestion is made by J. E. Boylan, who advocates ablation 



o 




v^ 



o> 




Fig. 24. — Sajous' Nasal Snare. 
With Adjustable Wire Loop, a, This cut shows the exact size of the tip, stilette and 
loop, b, This cut shows the manner of introducing the wire loop, c, Sajous' Snare as 
modified by Dr. S. MacCuen Smith. 



CHRONIC RHINITIS. 



33 



in preference to cauterization. The point of a fine tenaculum 
bent at a little more than a right angle is buried in the tur- 
binate body posteriorly where we desire the wire to cut and 
and thus the amount of tissue included may be accurately de- 
termined by passing the loop over the hook. In order to prevent 
slipping anteriorly a shallow incision is made in the base of the 
turbinate and in it the wire is inserted. The hot wire loop for these 
minor operations within the nares is not to be recommended. With 
it there is danger of damaging adjacent parts which we wish to 
preserve. It should be reserved for those in whom we have reason 
to fear hemorrhage. For ordinary use Sajous' modification of 
Jarvis' snare is a most convenient instrument (Fig. 24). In tumors 




Fig. 25. — Wright's Snare. 



of unusual dimensions it will be necessary to use the original Jarvis 
snare, which permits unlimited expansion of the loop; one end of 
the wire being fixed, the other end may be played out to any extent 
desired. The Sajous snare, however, will carry a loop only so large 
as its screw thread will exhaust. The great advantages of the latter 
are the ease with which it is prepared for use and with which the 
loop may be turned and manipulated, especially in a narrow nostril, 
from the fact that the ends of the wire are fixed at the distal end of 
the instrument. For polyps, neoplasms of medium size, and hyper- 
trophies the Sajous snare meets every requirement. The cold wire 
snare will cut through not only the soft parts, but the bone itself, and 
Lj 3 



34 DISEASES OF THE NOSE, THROAT AND EAR. 

is especially adapted to vascular ''mulberry" hypertrophies of the 
posterior end of the inferior turbinate and to enlargement of the mid- 
dle turbinate in which it is necessary to remove the anterior end of the 
bone (Fig. 25). In using the snare it is well to introduce as large a 
loop as the nostril will accommodate. If the patient is willing to en- 
dure the pain the loop may be adjusted before the use of cocaine, the 
inclusion of more tissue being thus assured. There is no danger 
of getting too much tissue, as is true with some of the forceps devised 
for removing the turbinate bodies. The difficulty is to remove 
enough to relieve the stenosis, and for that reason it may be desirable 
in some cases, for example, those in which the turbinate bone must 




Fig. 26. — Casselberry's Nasal Scissors. 

be sacrificed, to use serrated scissors like those proposed by Cassel 
berry (Fig. 26), or the author's cutting forceps (Fig. 27). In order 
to prevent hemorrhage the loop of the snare should be tightened 
very gradually. In vascular posterior hypertrophies, which are 
apt to bleed profusely, a half hour or more may be consumed in 
making the section. On the other hand, some patients prefer to 
have the snaring done quickly at the cost of a little more pain and 
loss of blood. By following the latter course we are informed at once 
of the amount of bleeding, whereas otherwise, we may send our patient 
away with a feeling of security only to be summoned later to check 
a violent secondary hemorrhage. Since the introduction of cocaine 
episodes of this kind have been more frequent, probably owing both 
to reaction from the temporary hemostatic effect of the drug and to 
the more rapid work which the local anesthesia permits. 

The electric cautery judiciously used, is one of the most valuable 
agents at our command. It has gained a measure of disrepute as a 
result of misuse. Unsuitable cases have been submitted to it, an 



CHRONIC RHINITIS. 



35 



improper degree of heat has been employed, imperfect batteries and 
apparatus have been the source of great annoyance. As a result 
instances of violent inflammatory reaction, extending even to the 
meninges, have been reported, violent hemorrhage has followed the 
withdrawal of an excessively hot electrode, and batteries often 
failed to work at critical moments. At the first sitting only a very 







Fig. 27. — Author's Cutting Forceps, a; Dressing Forceps, b, and Scissors, c. 

moderate amount of burning should be done and the utmost care 
must be taken to exclude possible contraindications. An incipient 
febrile state or a condition of systemic depression may be sufficient 
reason for postponing a cauterization, which is by no means always 
the trifling operation some profess to believe. A convenient source 
of current for surgical use is the storage battery, of which there are 
several varieties in the market. Being portable it may be used at 



36 



DISEASES OF THE XOSE, THROAT AXD EAR. 



the bedside as well as in the consulting room. It has the disad- 
vantage of requiring frequent recharging according to the amount 
of work demanded of it. Several efficient controllers have been 
designed for the street current and are more satisfactory for office use. 
The selection of electrodes, handles and conducting cords is impor- 
tant. These articles are generally unnecessarily heavy and clumsy. 
In using electricity we should remember that the result is accom- 




Fig. 28. — Schech's Handle for Cautery Points. 

plished by the heat and not by the application of force, hence, cum- 
bersome apparatus is superfluous. The electrodes should be delicate, 
the handles light, and the cords not too thick and stiff. Attention to 
these details adds greatly to our comfort and satisfaction in using 
electricity. An excellent set of electrodes for the nose, larynx and 
pharynx with handles of ebony and bone, is known as Schech's 
(Figs. 28 and 29) . The Kuttner handle made of metal and vulcanite 
is very serviceable, but is heavier. The degree of heat advised by 
most operators is "a cherry heat." Less heat fails to destroy to a 




Fig. 29. — Schech's Handle for Cautery Loop. 



sufficient depth and is more painful while much more than cherry 
heat is sure to cause bleeding. With cocaine the question of pain 
does not arise, and if, as is to be preferred, the electrode is applied 
cold to the surface to be burned the degree of heat must be just on 
the border line between cherry and white. Cocaine is of great 
service not only as an anesthetic, but in clearly defining areas of 
hyperplasia to be destroyed from other regions which are to be 



CHRONIC RHINITIS. 37 

avoided by the electrode. The nostril to be operated upon having 
been thoroughly cleansed with an alkaline wash, cocaine in 10 per 
cent, solution is applied on pledgets of cotton, the head of the patient 
in the meantime being bent forward to obviate the passage of the 
solution backward into the pharynx. In operating far back in the 
naris the avoidance of this accident is impossible, and the patient 
should be forewarned of the unpleasant consequences. Unless the 
nostril is excessively narrow, a septal shield, or a special speculum 
for protecting the septum is not necessary. The cold platinum 
point being pressed firmly into the tissues the current is turned on 
for only a few seconds and no damage is done except at the line of 
contact. The electrode should be gently withdrawn before it has 
quite cooled. Otherwise, it adheres and its detachment causes 
bleeding. A little experience and care are needed to carry out this 
step of the manipulation successfully. We thus burn through the 
whole thickness of mucous membrane with two objects in view, first, 
to destroy redundant tissues and, second, to promote absorption by 
the resulting cicatricial contraction. Unless this secondary effect is 
kept in mind more burning than necessary may be done. On the 
other hand, timid and superficial burning often does more harm 
than good by aggravating the irritable membrane. The cauteriza- 
tion should be thorough, but over a limited area. At the end of a 
week or ten days this process of linear cauterization may be repeated 
if it seems to be required. The use of a sharp-pointed electrode to 
be passed into the submucous tissues before the current is turned on 
has been proposed with a view of preserving as far as possible the 
surface of the membrane. The effects of the cautery in destroying 
the epithelium and in obliterating the canaliculi in the basement 
membrane, with subsequent formation of new connective tissue, 
dilatation of the gland ducts and more or less recurrence of nasal 
obstruction have been demonstrated by Goodale and others. So 
serious do these objections appear to some that punctate rather than 
linear cauterization is advocated with a view of interrupting the 
tissue destruction (B. Douglas). By others the cautery is discarded 
and various substitutes are proposed. D. A. Kuyk makes an inci- 
sion through the mucous membrane to the turbinate bone, which is 
then deeply furrowed with a broad saw. Into this furrow the edges 
of the incised membrane are tucked and held with a tampon of 
cotton soaked in equal parts of compound tincture of ben :oin and 



$8 DISEASES OE THE NOSE. THROAT AND EAR. 

collodion. Removal of redundant tissue and primary union of the 
wound are the principles involved in an elaborate operation devised 
by Yankauer. The soft parts having been cut away by incisions 
above and below the redundant portion, enough of the bone is 
removed with punch forceps to permit the lips of the wound to be 
brought together with catgut sutures. A number of special instru- 
ments are needed in order to enable one to carry out the technical 
details with satisfaction. The advantages are abbreviation of the 
process of repair and decrease in risk of local sepsis. As a matter 
of fact, in most cases the whole thickness of the mucosa is involved 
in the morbid process, it cannot be supposed that a dense hyper- 
plastic turbinate is capable of performing its normal function, and 
there is no object in attempting to save the surface. The foregoing 
observation applies with equal force to sub-mucous injection of 
acids or other solutions intended to shrink the tissues and to various 
ingenious plastic operations upon the turbinate bodies which have 
a similar end in view. Interest in these conservative methods 
seems to have been recently revived and we rind sub-mucous in- 
jections of zinc chlorid in ten per cent, solution advised by Gaudier, 
who however admits that results are uncertain and that cauteriza- 
tion or resection of the turbinate must be resorted to in many 
cases. The experience of Hamm. Viollet and many others author- 
izes the conclusion that a dense hyperplasia cannot be satisfactorily 
reducea in this way. The interstitial application of chromic acid 
is facilitated by the use of Goldstein's " turbinal trocar." The trocar 
and canula. the latter provided with an adjustable ring for regulating 
the depth of insertion, are plunged into the hypertrophied tissues and 
after withdrawal of the trocar a probe armed with chromic acid is 
passed through the canula and drawn out together with it. Thus a 
line of caustic is deposited along the track of the instrument. .Al- 
though these methods may be simple of execution, painless under 
cocaine, free from violent reaction and from the danger of adhesions, 
we fail to see their advantages or efficacy in genuine hyperplasia, 
while in simple hypertrophy milder methods will generally suffice. 
In certain cases of nasal obstruction due to chronic turgescence of 
the turbinates from vasomotor derangement Delavan proposes to 
effect retraction of the swollen tissues by submucous incisions, thus 
dividing and ultimately obliterating the venous sinuses. A very fine 
lance-pointed knife or needle is used and punctures are made at 



CHRONIC RHINITIS. 39 

different points according to the extent of swelling. The results of 
this method are said to be permanent. 

Nearly all the chemical caustics, from strong nitric acid down, have 
been tried in hyperplastic rhinitis. They share the objection that, 
unless extreme care be exercised in applying them, they are apt to 
spread and burn over too wide an area. At the present time chromic 
and trichloracetic have supplanted other acids. There seems to be 
no decided choice between them, except on the ground that toxemia 
may result from the former in case it is applied too freely, or of 
individual idiosyncrasy. Chromic acid is kept in crystalline 
form and at the moment of using a few crystals are fused on the 
end of a probe. A copper wire, five or six inches long, flattened 
at its end for half an inch, makes a good applicator. The acid is 
deliquesced by the addition of water and the flat end of the probe 
is dipped in the solution. One side of the probe being wiped dry 
with a bit of absorbent cotton the other side remains charged. 
Thus armed the copper probe can do no harm to the septum, for 
instance, when we wish to burn only the turbinate body. The 
action of the acid is very prompt. It soon exhausts itself upon the 
tissues and there is no need to neutralize it unless an excessive 
quantity has been accidentally used. Within a week the eschar 
thus produced separates or comes away in fragments and another 
application of the acid at the same spot is usually required. There 
is seldom any complaint of pain or reaction, except in neurotic 
subjects, or in case the application may have been extravagant. 
Some patients object to the disagreeable odor of chromic acid. In 
such the trichloracetic acid is preferred. Its energy of action is 
almost, if not quite, equal to that of chromic acid. It is pleasanter 
to' handle and is free from toxic qualities. It is used with a Gleits- 
mann applicator, or may be applied by means of a fine nasal 
probe wound with a thin film of absorbent cotton. 

While the active treatment is being carried out local cleanliness and 
asepsis must be maintained by the use of sprays and irritating condi- 
tions of all kinds must be remedied as far as possible. The patient 
should be seen every two or three days and the formation of adhesions 
guarded against by the passage of a probe until healing and retrac- 
tion have well progressed. 

A form of nasal obstruction in which the inferior meatus is almost 
completely obliterated by thickening of all the tissues composing the 



4Q 



DISEASES OF THE NOSE, THROAT AND EAR. 



inferior turbinate body is quite common. The current of air in 
respiration passes by the middle meatus while the floor of the nose 
is occupied by the swollen turbinate bathed in detained secretion. 
The drainage and ventilation of the nasal chamber are manifestly 
defective, and although the patient may respire through the nose by 
day he becomes a mouth-breather at night, the posterior nares and 




IJ 



Fig. 30. — Berens' Spoke Shave. 



pharynx giving evidence of the latter. In order to remedy this con- 
dition the bone itself must be removed. This may be done with a pair 
of strong nasal scissors. The anterior end of the bone is usually 
most at fault and especially in a narrow nostril it is necessary to apply 
the blades of the scissors well down at the base of the turbinate. In 
extreme cases the saw or the cold snare works well, or one of the 
various conchotomes (Fig. 30) may be preferred. The so-called 






CHRONIC RHINITIS. 4 1 

nasal plane, or spoke shave, has justly lost its popularity. It is apt 
to carry away too much tissue and many cases of alarming hemor- 
rhage after its use have been reported. The objects in view are to 
restore the normal patency of the nostril and leave a smooth sym- 
metrical stump. With strong solutions of cocaine (10 to 20 per 
cent.) and adrenal extract, this operation of turbinectomy, which 
should never be a complete resection of the bone, may be done pain- 
lessly and bloodlessly. Attempts at twisting off a turbinate body or 
avulsion with forceps are not to be recommended. The entire bone 
might be dislocated by immoderate violence. Plugging the nostril 
except for hemorrhage does not seem desirable, although Lake's 
india-rubber splint, or similar dressings of celluloid are used by 
many. In the opinion of Pegler the rubber splint, which is aseptic 
and easily removed and kept clean, saves the necessity of subse- 
quent trimming in consequence of the gentle uniform pressure it 
exerts upon the roughness inevitably left by the operation. Simp- 
son's tampons of Bernays' compressed cotton, especially when cov- 
ered with rubber tissue, collodion, or a thin sheet of vulcanite as 
suggested by Chappell, are sometimes useful in suppressing excessive 
granulation, but they must not be left in too long, and care should be 
taken not to use too thick a tampon lest in expanding it cause 
intolerable pressure. It is the belief of the author that most of these 
cases do better without ^uch a foreign body in the nose even though 
it may not be very irritating. The case should be carefully watched 
during convalescence and exuberant granulations should be reduced 
with the knife or a light touch with the electric cautery. 

The use of hot air, first suggested by Vansant for the relief of head- 
ache, has been recommended in various morbid conditions of the 
nasal membranes by Lermoyez and Mahu and more recently by 
Lichtwitz. The current of air, at a temperature of 70 to oo° C, is 
propelled against the affected surface by a special mechanical device, 
consisting of an electromotor pump and an arrangement for warming 
the air, and is said to exercise a beneficial effect not only in simple 
engorgement of the erectile tissue but also to some extent in hyper- 
plastic conditions. It is possible to conceive that the nutrition of an 
affected area may be so changed by continuous or oft -repeated 
applications of heat as to arrest a diseased process or possibly to 
promote absorption of inflammatory products, but a dense organized 
hyperplasia would certainly not seem to offer a highly encouraging 



42 DISEASES OF THE NOSE, THROAT AND EAR. 

field for experiment with such a method. It is believed that more 
rapid and radical procedures will give more satisfaction. 

The question is often asked whether the results of treatment or 
operation are permanent. In the majority of cases it is safe to 
answer in the affirmative provided the causes which instituted the 
catarrhal process can be discovered and eliminated. So many ele- 
ments are concerned in many cases, as regards both the individual 
and his environment, that it is not always possible to ensure this 
provision. But should signs of nasal insufficiency recur after a 
longer or shorter interval owing to reestablishment of hyperplasia 
that fact would be no reason for abstaining from treatment. It is a 
simple matter to repeat a cauterization if necessary, and the principle 
should be constantly kept in view that wholesale destruction of 
intranasal tissue is not the chief end of rhinology. Attempts to 
restore the function of crippled structures are far more commendable 
than substitution of cicatrices for erectile tissue even though the 
latter be impaired. In many cases digestive or systemic derange- 
ments are of first importance, and endonasal surgery should be 
looked upon as a last resort. 



CHAPTER III. 

ATROPHIC RHINITIS. MEMBRANOUS RHINITIS. CASEOUS RHINITIS. 
PURULENT RHINITIS. 

Atrophy is a sequel of inflammation rather than itself an inflam- 
matory process. Various theories have been proposed to account 
for it. The majority of cases result from antecedent hyperplasia, 
the atrophic change in the nasal membrane being due to lessened 
blood supply from interstitial pressure which obliterates the vessels 
and at the same time interferes with innervation and glandular 
function. Some authorities believe in a primary atrophy and, in a 
certain proportion of cases, it is impossible to find evidence of 
preexisting hypertrophy. A third theory, of which Bosworth is the 
principal champion, refers the atrophy to a purulent rhinitis as met 
with in children. Other observers, notably Cholewa and Cordes, 
maintain that the process begins in the bone, thence invading the 
mucous membrane. The argument in favor of this view is extremely 
plausible. Progressive bone absorption, due to causes not yet ex- 
plained, obliterates the radical arteries and veins lying side by side 
in the bony canals, whence a portion at least of the blood supply of 
the soft parts is derived. In consequence the nutrition of the 
mucous membrane suffers and atrophy ensues. The causes which 
institute these alleged primary bone changes are not disclosed, but 
the admission of their existence in a measure explains the inefncacy 
of treatment in many cases of atrophy. Some authorities regard it 
as of neurotic origin, a trophoneurosis, and still others as consequent 
upon disease of the accessory sinuses (Griinwald). The sinus or 
"focal" theory is weakened by the frequent occurrence of atrophy 
without involvement of a sinus, as well as by its practical cure 
while a sinusitis still persists. On the other hand a sinusitis may be 
cured with no change in a coincident atrophy. The constitutional 
dyscrasia generally present is considered by some a result, by others 
a cause, of the nasal lesion. Congenital deformities of the nasal 
fossae, especially a short antero-posterior diameter (platyrrhiny), arc 
looked upon as favoring an atrophic process. The discovery of 

43 



44 DISEASES OF THE NOSE. THROAT AND EAR. 

certain bacteria in the secretions of an atrophic rhinitis has led to 
the adoption of a bacillary theory. Finally, a recent hypothesis is 
based on the observation that a metamorphosis of columnar into 
squamous epithelium, or an "epithelial metaplasia." may exist 
from infancy or birth. This condition is thought to be an etiological 
factor, especially in the presence of marked disproportion between 
the vertical and lateral diameters of the skull giving abnormal width 
to the nasal fossae. Malformations, particularly imperfectly de- 
veloped turbinate bones, and spurs and deviations of the septum 
are undoubtedly predisposing causes. Atrophy is apt to follow also 
various exanthema tous diseases. It is usually met with rather 
early in life, a fact which has given prominence to the idea that 
purulent rhinitis is a predisposing cause. The influence of micro- 
organisms is by no means determined; their presence cannot be 
denied, but it is probably nothing more than a coincidence. On the 
other hand, it is the opinion of Lermoyez that the active causative 
agent is the so-called bacillus of Perez, which is said to be capable of 
developing the characteristic ozena and of creating the disease by 
animal inoculation. These facts being admitted, a belief in its 
contagiousness follows and measures to prevent transmission are 
demanded. 

It is clear that no single theory explains even* case and that in 
s mc several of the causes, or conditions, mentioned are concerned. 
From a clinical standpoint the evidence that hyperplasia tends to 
promote atrophy is conclusive, a vie sustained by microscopic 
testimony. 

In the early - ges :£ many cases :: sc -called atrophic rhinitis the 
pathological changes are limited to the mucous membrane and con- 
stitute a true fibrosis. Eventually bone involvement may occur. 
The latter is thought by some to be especially frequent in tubercular 
and syphilitic subjects. The changes in the membrane consist in 
the usual connective tissue overgrowth following chronic innam- 
matory processes which result in contraction. This so-called sub- 
mucous cicatricial contraction involves the blood-vessels as well as 
the glandular elements, the degree of functional disturbance and the 
prognosis depending upon its extent. 

The die.::: of atrophic rhinitis may sometimes be made from 
the fetid odor alone. On inspection of a nasal fossa affected by 
atrophy the passacrs are found more or less clogged with masses of 



ATROPHIC RHINITIS. 45 

inspissated secretion the removal of which exposes the membrane, 
pale in color and obviously thinned. The shrinkage may be univer- 
sal or limited to certain areas and, on palpation with a probe, it is a 
simple matter to demonstrate the extent of the atrophied surface. 
In extreme cases, it is possible on anterior rhinoscopy to see the 
posterior pharyngeal wall and the action of the palatal muscles is 
plainly visible while the patient pronounces a nasal consonant. It 
is necessary to distinguish genuine atrophic rhinitis from two other 
conditions which resemble it in some respects. More or less con- 
fusion has prevailed and difference of opinion as to prognosis and 
treatment has arisen from a failure to differentiate these various con- 
ditions. In the first place we should recognize the occasional exist- 
ence of a vascular collapse of the nasal erectile tissue accompanied 
by dryness of the mucous membrane. This is much more common 
in anemic persons and in the female sex. There is no characteristic 
physiognomy such as we see in advanced atrophy. The mucous 
membrane is pale and retracted on the subjacent bone. The condi- 
tion usually involved both nostrils. There may be no impairment 
of the sense of smell. There is no odor perceptible and the secre- 
tions are scanty. The condition may disappear under improve- 
ment in the general health and requires no attention locally. 
Secondly, there is a form of rhinitis with diminished mucous secre- 
tion, called rhinitis sicca which is observed in adults, usually of the 
male sex, in those of full habit and a gouty tendency. The mucous 
membrane, instead of being pale, is congested. The turbinate 
bodies may be turgescent. There may be erosions, especially of the 
septum, possibly accompanied by perforation. Frequently the con- 
dition is unilateral, but it is generally seen on both sides. It is not 
readily curable by local measures alone, but improves under the use 
of antilithic remedies. 

The symptoms of atrophic rhinitis relate chiefly to disturbances 
caused by altered secretion. The mucus loses its fluid, serous char- 
acter, tends to become rapidly inspissated, and form characteristic 
crusts or scabs which attach themselves firmly to the mucous mem- 
brane and are very difficult to remove. Their extraordinary 
adhesiveness is regarded by some as an etiological factor, the 
vitality of the subjacent tissues being impaired by the compression 
they exert. The retention of these crusts is due not only to their 
character but to the fact that abnormal widening o\ the nasal pas- 



46 DISEASES OF THE NOSE, THROAT AXD EAR. 

sages prevents the blast of expired air from exerting its usual force. 
The disappearance of cilia from the epithelium, a constant phe- 
nomenon in atrophy, is no doubt an important factor in derangement 
of secretion. True ulceration of the mucous membrane is rare, but, 
when it exists, is a result of the habit of picking the nose to dislodge 
accumulated secretion. Xosebleed may result from violent attempts 
to clean the passages by blowing. The patient has a constant 
feeling of stuffiness and desire to blow the nose even when the 
accumulated material is not excessive. One of the most distressing 
symptoms in bad cases is the fetid odor, or ozena, a term which is 
mistakenly applied by some to the disease itself. It should be 
reserved for the symptom of the disease since ozena is met with not 
only in atrophic rhinitis but in syphilis, malignant disease, and in 
obstruction from a foreign body or from deformity or disease of the 
nasal fossae. It is much more pronounced in some cases than in 
others. If the patient himself has lost the sense of smell it may 
not be perceptible to him. Fetor seems to be quite independent of 
the quality and the quantity of secretion, frequently being very 
marked when the latter is scanty. According to Freese. it is due to 
acid decomposition of the fatty and albuminous constituents of the 
secretions. Xo doubt in some cases the fetor may be traced to 
secretions retained in an accessory sinus, but pronounced ozena is 
not unusual when these adjacent cavities are above suspicion. In 
certain individuals there seems to be some inherent quality in the 
tissues or secretions whence emanates a peculiar odor analogous to 
that sometimes observed from the sweat glands. There is seldom 
any pain although the patient may complain of a dull, heavy sensa- 
tion over the bridge of the nose and in the frontal region. On the 
other hand severe headache especially in the forehead may occur. 
Many patients show rather sluggish mental operations and are very 
apt to be depressed in spirits. Xot infrequently secondary disturb- 
ances of the pharynx and larynx occur and gastric derangements 
are often met with and. sooner or later, distinct impairment of the 
general health is noticed. The latter fact, in conjunction with an 
obstinate cough often present, is likely to excite apprehension of lung 
disease. In well-marked cases a peculiar facial expression, shown 
in the widely expanded nostrils, snub-nose, the dull countenance and 
thick lips, is thought to be characteristic. 

The treatment of atrophic rhinitis has in view two objects: the 



ATROPHIC RHINITIS. 47 

correction of the fetid odor and the restoration of glandular function. 
The former is always feasible, the latter is not when the process of 
degeneration has advanced to an extreme degree. The fact that the 
disease, if not caused by a constitutional diathesis is certainly aggra- 
vated by a depressed state of the general health suggests the neces- 
sity of combining local with general treatment. The use of tonics, 
attention to hygiene and the correction of digestive derangements 
are of the greatest importance. 

The internal use of mucin, especially with a view to its influence 
upon secondary derangements of the digestive tract, has recently 
been urged. It is given in tablets containing five grains each of 
mucin and bicarbonate of soda. A watery solution is used as a 
douche to the nose and pharynx. It is said to counteract the dryness 
of the membranes and to relieve the gastrointestinal disorders which 
are a frequent consequence of deficiency of normal mucous secretion 




Fig. 31. — Lefferts' Postnasal Syringe. 

due to atrophy (Stuart Low). The antagonism supposed to exist 
between the flora of the nose and of the mouth suggests the use of 
the saliva as an intranasal germicide. The unique proposal is 
made by Iglauer to establish an oronasal fistula through which the 
patient may at will give his turbinate bodies a salivary bath. 

In approaching the question of local treatment we are amazed at 
the large number of drugs which have been resorted to at various 
times. The inference is that in general experience the disease has 
been found rebellious to treatment. So true is this that many 
practitioners conclude that cleanliness is all that can be accomplished 
by any course of treatment whatever. While this may apply to the 
worst cases of atrophic rhinitis, nevertheless if the process be identi- 
fied at its inception much maybe done. There is no question that 
thorough cleansing of the surface is important before medication 
should be attempted. The removal of the dried secretion is often a 
very difficult process and cannot be effected by the patient himself. 
at least, at the outset of treatment. Simple douching of the nose or 



4 8 



DISEASES OF THE NOSE, THROAT AND EAR. 



spraying is only a partial mode of accomplishing the end and must 
be supplemented by systematic brushing of the surface of the mucous 
membrane with sterilized cotton wound on the end of a nasal probe. 
It is a good plan first to soften the secretions thoroughly by means 
of a coarse spray or douche of normal salt solution as hot as the 
patient can comfortably bear. In some cases when the crusts invade 
the nasal pharynx it is necessary to cleanse from behind forward by 
means of a postnasal syringe (Fig. 31) or Holmes : postnasal douche 
(Fig. 32). Having removed all the secretions we are prepared for 
the application of an agent which will stimulate glandular action 




Fig. 32. — Holmes' Post-nasal Douche. 

provided the glands have not been entirely destroyed. One of the 
best applications for the purpose in most cases is a solution of men- 
thol in albolene in the proportion of ten grains and upward to the 
ounce. This may be applied twice a day after the use of the salt 
water. An excellent stimulating application is a solution of 
formaldehyde, an agreeable preparation of which is borolyptol 
which contains 1 to 500 of formaldehyde. This must be still 
further diluted since it is very irritating, but it has the double 
advantage of stimulating the mucous membrane and acting as a 
powerful deodorant. Citric acid in powder with an equal quantity 
of sugar of milk has been observed to control the fetor and crust 
formation. Nitrate of silver, in solution of twenty to sixty grains to 
the ounce, or even stronger, has been widely used but seems to offer 
no advantage over other preparations less disagreeable to handle. 
Some of the modern compounds of silver, protargol and argyrol, 
may be destined to find a permanent place in therapeutics. Hydro- 



ATROPHIC RHINITIS. 49 

gen dioxide finds favor with many practioners, who accept the 
bacterial theory of origin. Even if germs are concerned, attempts 
to render the nasal chambers absolutely sterile are of doubtful 
expediency. Solutions strong enough to accomplish the orjject 
must endanger the vitality of the tissues. It remains to be seen 
whether injections of the lactic acid bacillus are of service. Theo- 
retically they should be, and quite encouraging reports have been 
made by North, Curtis and others, while in some of our large clinics 
results have been negative or worse. 

An ideal antiseptic, if all that is claimed for it be true, is offered 
in gomenol, a vegetable product said to possess extraordinary germi- 
cidal power while being free from irritating properties. It is the 
ethereal oil of melaleuca viridiflora, a plant growing near Gomen in 
New Caledonia. A 10 to 50 per cent, solution in sterilized olive oil 
is an agreeable and effective application. One of the best prep- 
arations, provided its odor is not objectionable, is ichthyol, which 
is used in a 5 per cent, solution in kerolin or, as preferred by many, 
in much stronger solution, or even in a pure state over a limited area. 
When a deformity or stenosis interferes with nasal drainage or forms 
a site for the lodgment of secretion it should be removed; otherwise 
no intranasal operation is advisable. Superficial erosions usually 
undergo repair without special attention as the secretions and the 
membranes acquire a more healthy character. In some cases a 
dilated naris, due to deviation of the septum, admits an excessive 
volume of air which may be reduced by wearing a film of absorbent 
cotton in the nostril or by replacing the deflected septum. Some of 
these patients are persistent mouth-breathers, although the nares are 
sufficiently spacious. They complain that they cannot feel the air 
in breathing through the nose, a state of things due to anesthesia of 
the mucosa. The idea of making an artificial turbinate by means of 
submucous injections of paraffin has been suggested by Richard 
Lake. In a case of bone absorption the abnormal width of the nasal 
canal was counteracted by bolstering up the soft parts with Eve- 
minim injections of paraffin made at weekly intervals until a body c\ 
proper size was formed. The relief of discomfort was complete. 
A similar proposal has been made by Brindel who claims to have 
observed disappearance of the tendency to stagnation and drying of 
secretion and actual restoration of normal glandular function. In 
extreme cases this method is impracticable owing 10 the difficulty 
4 



50 DISEASES OF THE NOSE, THROAT AND EAR. 

in inserting the needle between the bone and its thin covering of 
mucous membrane (Burger). 

The effects observed from the use of dionin (ethylmorphine) in the 
eye led to its adoption in nasal atrophy (Stiel). It seems to have the 
capacity to cause swelling of the turbinates without excessive ir- 
ritation. The secretions gradually become more normal and crust 
formation diminishes. The drug is used in the form of powder, or 
in 5 to 10 per cent, solution. 

The application of Bier's artificial hyperemia to atrophy com- 
mends itself by its tendency to promote nutrition and stimulate 
functional activity. It is still under trial. 

The great interest in serum therapy naturally excited the hope 
that something might be accomplished in that line in atrophic 
rhinitis. Many experiments have been made resulting in wide 
divergence of opinion. The discovery in the secretions of a "diph- 
theria-like" bacillus has led some observers to declare that atrophy 
is a form of chronic nasal diphtheria. Some claim to have cured 
advanced cases by the repeated injection of ten centimeters of 
Roux's diphtheria antitoxin. Others pronounce this dose excessive 
and allege that the treatment is dangerous although it gives positive 
results in the disappearance of dryness and crust formation with 
the relief of ozena. This is not likely to supersede safer and equally 
efficacious modes of treatment. 

In addition to the medicinal agents already mentioned for treating 
atrophic rhinitis we have at command various resources more or 
less serviceable. Nasal bougies, medicated, or otherwise, have been 
used. Plugs or tampons of cotton have been recommended with the 
idea of partially obstructing the nasal passages for the purpose of 
inducing more or less congestion of the mucous membrane with in- 
creased functional activity. The method of Gottstein consists in 
packing the nasal fossae with dry non-absorbent wool which is 
renewed at the end of twenty-four hours. Thus a tendency to 
crust formation is corrected, a more healthy action of the glands is 
established and the mucous secretion becomes more fluid. A plan 
for removing as well as preventing the formation of crusts is urged by 
Sondermann. A flexible rubber bag is passed into the naris and 
then dilated by means of a hand bulb. The bag adapts itself to the 
irregularities of the nasal fossa and when withdrawn in five or ten 
minutes is found to bring with it the tenacious secretions. The 



ATROPHIC RHINITIS. 5 1 

process is repeated once or twice a day as may be required. Areas 
of eroded granular membrane underlying crusts of dried secretion 
are sometimes encouraged to repair by application of a sharp 
curette, but it should be used with caution since our efforts should be 
directed to the preservation and restoration of tissue. Electrical 
treatment of atrophic rhinitis is applied in the form of the galvano- 
cautery in cases similar to those in which the curette is admissible; 
second, by the constant or interrupted current; and, third, by 
electrolysis. Their effect with the exception of that first named 
consists in stimulation of glandular function and is good in cases 
not too far advanced. These methods are tedious and require 
frequent repetition and special apparatus. The use of galvanism 
gives excellent results in suitable cases, that is, those in which the 
glands have not been completely obliterated by the atrophic process. 
A flat sponge electrode connected with the positive pole of a constant 
current battery is applied to the nape of the neck. The negative 
pole, a metallic electrode, is placed in direct contact with the mucous 
membrane of the nose. It is rather more agreeable to the patient to 
use in the nose a copper wire electrode loosely wound with absorbent 
cotton. If both nostrils are to be treated the nasal attachment may 
be double, a section for each nostril, as suggested by Delavan. The 
strength of the current should not exceed seven milliamperes and 
the duration of each sitting should not be more than twelve minutes. 
The patient feels a sensation of warmth but no pain, unless the 
current is too strong. A slight watery secretion is excited by the 
application and in course of time the quality of the nasal mucus is 
perceptibly improved. 

Cupric electrolysis is warmly commended by some observers. 
Strong currents are very painful and a general anesthetic may be 
required. Watson Williams, who claims better results with this 
than with any other method of treatment, prefers mild currents at 
intervals of two or three weeks until increased secretion and vascu- 
larity and diminished fetor are noted. The parts having been 
cocainized " a copper needle attached to the positive pole is inserted 
into the tissues of the inferior or middle turbinated body, and a 
steel needle, attached to the negative pole, into the septum, and a 
current of from five to ten milliamperes is passed from ten to fifteen 
minutes." This process should be repeated until the symptoms 
yield and on signs of recurrence. The results of vibratory massage 



5 2 

are not especialy encouraging and the proposal of Flatau to excite 
tissue proliferation and increased secretion by driving ivory pins 
into the turbinate bone will hardly appeal to a large number. 
The curative effect of erysipelas in nasal atrophy noted by several 
observers has led to the suggestion that injections of Coley's fluid 
might be useful in cases of this kind (Somers). The symptoms and 
consequences of atrophy seldom justify taking the risks of such 
treatment. 

Phototherapy and radiotherapy are said to have given good 
results. The only objection is the occasional occurrence of head- 
ache and vertigo (Dionisio). Special apparatus is required. 

Spontaneous recovery sometimes takes place, that is the symp- 
toms cease although normal tissues may not be regenerated. In 
adolescents approaching puberty and in women at the menopause 
amelioration follows when these critical periods have been passed. 
Whatever course of treatment be selected in a case of atrophic rhinitis 
pronounced results must not be expected in weeks or even months. 
The secret of success lies in the early adoption of a systematic 
regime, which includes both local and general medication and which 
must be continued with persistence. 

MEMBRANOUS RHINITIS. 

An inflammation of the nasal mucosa characterized by the forma- 
tion of a membranous or fibrinous exudate is occasionally seen in 
which the membrane shows no tendency to invade the pharynx and 
which is not attended by any indications of constitutional disturb- 
ance. The condition differs from diphtheria in being a much milder 
type of disease as regards local as well as general disturbance. There 
may be some rise of temperature and a good deal of nasal stenosis 
but there is no sign of sepsis and the disease is not contagious. It 
differs from diphtheria also in that glandular involvement is rare, 
the diphtheritic odor is absent and the Klebs-Loefner bacilli seldom 
can be found. The membrane is easily removed and generally re- 
forms. Similar conditions are seen after the use of strong caustics in 
the nose and after the galvanocautery especially in those depressed in 
health and ill nourished. The importance of the diphtheria bacillus 
in membranous inflammations is opened to question by the discovery 
by Meyer of large numbers of virulent bacilli in membrane formed 



CASEOUS RHINITIS. 53 

after the use of the galvanocautery as well as in a majority of cases 
of fibrinous rhinitis. In a great variety of nasal diseases examined 
by Vansant the mucous secretion showed the presence of the diph- 
theria bacillus in a large percentage. Pluder believes that fibrinous 
rhinitis is really a mild form of diphtheria, having found the bacillus 
in all of five cases examined microscopically. Either the Klebs- 
Loefner bacillus is of no consequence, or else there exist "true" and 
"false" bacilli which even expert microscopists differentiate with 
difficulty. Unless the possibility of infection be conceded the con- 
dition cannot be regarded as very important and active interference 
is not indicated. In some cases general tonics are desirable and 
the comfort of the patient is increased by gentle removal of the 
membrane and applications of antiseptics and mild astringents in 
oily solution. 

CASEOUS RHINITIS. 

The name caseous rhinitis is given to a rare and curious form of 
inflammation in which the nasal passages are occupied by a material 
resembling cheese or putty. It is said by some to develop in strumous 
individuals and in connection with nasal polypi. It would seem to 
be a result of fatty degeneration of secretion which has been long 
retained either in an accessory sinus or in the upper part of the nasal 
fossae. A prominent symptom is a sensation of stuffiness in the nose 
accompanied by headache. The sense of smell is usually lost and 
the fetor always present is not apparent to the patient. This state 
of things may be corrected by careful attention to cleanliness, the 
cheesy mass being thoroughly removed and the nasal cavities after- 
ward sprayed with antiseptic solutions. At the same time the 
morbid condition which gives rise to the perverted secretion must be 
found and eradicated. In a recent case in my own clinic an intoler- 
ably offensive mass of cheesy accumulation was removed from the 
nose of a fairly intelligent man whose only complaint was of head- 
ache and nasal stenosis. Such a condition could result only from 
the grossest neglect. This disease must not be confounded with a 
false rhinitis caseosa. The latter is always dependent upon a foreign 
body, a rhinolith, a tumor, or a chronic sinusitis, while in the true no 
such cause can be found.' Its dependence upon a specific microbe. 
the Streptothrix alba, as described by Guarnaceia, and its relation to 



54 DISEASES OF THE NOSE, THROAT AXD EAR. 

scrofula, as maintained by Cozzolino and others have recently been 
stoutly denied by Michele. Its rarity, the rapidity of its cure, the 
absence of recurrence, a single case having been reported by Massei, 
added to the fact that the disease is practically unilateral would seem 
to exclude a scrofulous origin. x\ccording to Michele no specific 
microbe can be found, hence if we accept this observer's views we 
shall still be in the dark as to the etiology of the disease. 

PURULENT RHINITIS. 

Purulent rhinitis is a variety of catarrhal inflammation of the 
mucous membrane in which pus formation is the prominent symp- 
tom. It is not intended to include in the term that form of rhinitis 
which occurs as a specific infectious disease transmitted to the new- 
born from the vagina of the mother. It occurs, as a rule, in infants 
as a result of exposure to irritants, either in the air or in the secretions 
of the maternal passages. The nasal discharge is very irritating and 
produces excoriation of the upper lip, and both nostrils are usually 
affected. There may be but little obstruction to nasal breathing. 
The secretion is more or less odorous, especially if the nostrils are 
not faithfully cleansed. A mucous membrane affected in this way is 
apt to be permanently impaired. By some observers this condition 
is believed to be an invariable precursor of atrophy. 

The treatment consists in careful cleansing of the nasal passages 
by an alkaline antiseptic solution, folloAved by an application of mild 
astringents. In many cases, indications of struma or constitutional 
impairment demand general as well as local treatment. 

A purulent nasal discharge in a child may be symptomatic of 
adenoids in the rhinopharynx. It may occur in syphilis or as a 
result of gonorrheal infection; in the former case the usual consti- 
tutional treatment is indicated, and in the latter precautions must 
be taken to prevent contagion and to protect the eyes. 



CHAPTER IV. 

DISEASES OF THE ACCESSORY SINUSES. ACUTE AND CHRONIC SINU- 
SITIS. HYDROPS ANTRI, OR SEROUS EFFUSION AND CYST OF 
THE ANTRUM. FOREIGN BODIES AND NEOPLASMS. 

The accessory sinuses when inflamed present certain features in 
common which may be considered before discussing individual 
cavities. 

Acute sinusitis may occur in connection with a "cold in the head" 
either as a result of direct infection or of swelling of the nasal mucous 
membrane which causes a damming up of secretion. It is met with 
in the course of the exanthemata, of typhoid, diphtheria and erysipe- 
las, and has been particularly observed as a complication or sequel 
of influenza. Acute inflammation of the sinuses may also follow 
traumatism and many cases are on record in which a foreign body 
has been driven into the frontal or maxillary sinus with the result of 
causing an acute empyema. The sphenoidal sinus and the ethmoid 
cells are less exposed to injury but similar cases have been reported 
in connection with these cavities. A blow on the face has been 
known to cause inflammation of the antrum and a case has been 
recorded by Rees in which empyema of the antrum in a child two 
weeks old resulted from compression of the head at birth. This 
must have been a precocious infant if, as we are told, the antrum of 
the new-born consists of a mere "indentation" on the outer wall of 
the nasal fossa. A tendency to spontaneous cure of an acute process 
undoubtedly prevails in the absence of any lesion or anatomical 
peculiarity which may act as an obstacle to evacuation of the prod- 
ucts of inflammation. 

A symptom invariably present in acute sinusitis is pain, as a rule 
referred to the region of the affected cavity and accompanied in the 
case of the frontal and the maxillary sinus by sensitiveness on ex- 
ternal pressure, and by swelling and possibly edema of the overlying 
soft parts. 

A chronic sinusitis may follow an acute attack, or may be charac- 
terized by absence of acute symptoms from the outset. The pain 

55 



56 DISEASES OF THE NOSE, THROAT AND EAR. 

associated with chronic sinusitis is seldom intense and its situa- 
tion is often of but little diagnostic value. For example, supra- 
orbital pain may be a symptom of antral rather than frontal sinus 
disease. In ethmoidal disease the pain is usually referred to the 
bridge of the nose, while in sphenoidal disease the back of the head 
is chiefly affected. A unilateral discharge of pus in the adult is 
always suggestive of sinus disease although bilateral sinusitis is by no 
means uncommon, having been found by Wertheim in 38.7 per cent, 
of cases of maxillary empyema. As a rule, the discharge is inter- 
mittent and is affected by change of posture; in other words a position 
that makes the outlet of the sinus more dependent facilitates drain- 
age. A peculiar musty odor is generally present which may be 
perceptible to the patient himself. The location of the pus is to 
some extent a guide as to its origin. Its color also is more or less 
distinctive, that from the antrum sometimes being light yellow or 
canary colored. It is probable that the variation in the physical 
characters of the purulent secretion in different cases is to be ex- 
plained in part by the great variety of microorganisms found in these 
conditions. The subject has been carefully investigated by Stancu- 
leanu and Baup, whose conclusions are interesting and may be of 
value with reference to determining the origin of a sinus empyema. 
Antral suppurations are divided into two groups. In the first there 
is an antecedent history of dental or alveolar disease and the pus has 
a decided fetor, due to the presence of anaerobic bacteria, or those 
whose growth is not dependent upon oxygen. The second group 
comprises those believed to be of nasal origin, the sinusitis followed 
an acute rhinitis, the teeth are sound and the secretion is mucopuru- 
lent and ropy. The pus is not fetid and is found to contain aerobic 
organisms, or those which grow only in the presence of oxygen. 
Further examination shows that microbes of the former kind 
inhabit the buccal cavity and are rarely found in the nose. The 
aerobic variety is met with in the nasal cavity and the purulent 
secretion it excites is more mucoid in character and is quite free 
from fetor. The pneumococcus either alone, or more frequently 
together with other microbes, is the organism most often found in the 
latter. In dental empyemas various bacilli may be discovered — 
ramosus, perfringens, serpens, theto'ides and fragilis and Staphylococcus 
parvulus in order of frequency — all exhibiting marked virulence 
when injected into animals. Similar results were obtained in 



THE ACCESSORY SINUS. 



57 



investigating the frontal sinus. In one case both forms of bacteria 
were found, the frontal sinusitis being consecutive to an antral 
empyema of dental origin. 

In cases of nasal suppuration in which sinus disease is suspected, 
the nostril having first been thoroughly cleansed of secretion, it is 
sometimes possible to detect a leakage of pus from the middle meatus 
under the concavity of the turbinate body, from which fact we infer 



f.s. 




■ry 11, 



Sp-f. p. B.C. 




sph. s. 



Fig. $$. — Sound in (a) Frontal, (b) Anterior Ethmoidal and (c) Maxillarv Openings. 

(Hajek.) 
f.s., Frontal sinus; o.e., ostium ethmoidale; m.t., middle turbinate cut off; s.L, superior 
turbinate; sp.t., supreme turbinate; p.e.c, posterior ethmoidal cells; sph.s., sphenoidal 
sinus. 



an affection of either the maxillary sinus, the frontal sinus, or the 
anterior ethmoidal cells. If pus is seen over the convexity of the 
middle turbinate, or between it and the septum, it is probably 
flowing from the posterior ethmoidal cells or the sphenoid sinus. 
Escape of pus from the antrum is encouraged by directing the 
patient to throw the head well forward and toward the sound side. 
When the patient lies down the pus flows backward and causes a 



58 DISEASES OF THE NOSE, THROAT AND EAR. 

bad taste in the mouth with gastric disturbance and morning nausea. 
The existence of polypi in the region of the middle meatus is apt to 
complicate an empyema of the antrum, of the frontal sinus, or of 
the ethmoidal cells, whether as cause or result is often hard to 
determine (Fig. 33). 

There seems to be no doubt that the accessory sinuses are affected 
by an inflammatory process much more often than has been supposed 
until within recent years, a fact explained in part by the prevalence 
of crude and superficial methods of examination and in part by the 
obscurity of symptoms in a large proportion of cases. Very many 
cases are put down as "nasal catarrh," and indeed in some of long 
standing those affected have no complaint to make except of excess 
of nasal discharge. This statement is corroborated by the post- 
mortem researches of E. Fraenkel, Harke and others. From 
studies conducted at Lichtwitz's clinic, where 243 cases of sinusitis 
were diagnosed in 12,000 patients, and from results announced by 
other observers, F. Martin concludes that indications of sinusitis are 
fifteen times more frequent in the cadaver than in the living subject. 
This discrepancy is accounted for in acute cases by the relatively 
greater prominence during life of symptoms referable to the general 
disturbance and in chronic cases to the latency of symptoms located 
in the sinus. Post-mortem records are not to be altogether relied 
upon, since pus in a sinus does not always mean inflammation where 
the fluid is found, and moreover inflammation if present may have 
been a recent development in the fatal illness and hence failed to 
attract attention during life. The obvious lesson is that a cursory 
inspection of the nasal fossae should not end the examination of a 
case of nasal suppuration. 

THE MAXILLARY SINUS. 

The antrum of Highmore, being the largest and most accessible 
of the sinuses, was supposed to be especially prone to suppuration 
until more exact and thorough methods of exploration taught us that 
the other adjacent cavities, notably the ethmoid cells, are involved 
with equal or greater frequency (Fig. 34). 

An acute inflammation of the antrum tends to resolve under favor- 
able conditions, that is, provided drainage through its normal outlet 
be adequate. The orifice of this cavity being much higher than its 



THE MAXILLARY SINUS. 



59 



floor, when the patient is erect, and liable to occlusion from swelling 
of the soft parts in its vicinity, an acute process is apt to degenerate 
into a chronic empyema. Acute maxillary sinusitis is said to be more 
frequent in men than in women. It may occur quite early in life. 
J. H. Bryan quotes Pedley as authority for a case in a child eight 
years old following caries of a canine tooth, and Shurly refers to a 
case noted by Power in a child eight weeks old due to traumatism by 
forceps during delivery, while Moure reports two cases in infants 




Fig. 34. — Vertical Cross Section Through Posterior Part of Nasal Fossa? Showing Their 
Relations to Adjacent Parts. (Zuckerkandl.) 
A, Roof; B, floor, and/ outer wall of cavity; aaa, superior, middle and inferior meati; 
b, middle turbinate bone; c, olfactory fissure, and d, respiratory fissure. 



hree weeks old from premature eruption of a tooth, one of the chil- 
dren being syphilitic. Bryan also describes an extension of nasal 
diphtheria and of phlegmonous pharyngitis to the antrum. When 
the inflammatory products are pent up within the cavity the symp- 
toms are so intense as to leave no doubt about the diagnosis. 

In treatment the indications are to subdue local reaction by warm 
applications externally and to promote drainage by reduction oi swell- 
ing in the middle meatus. Cocaine, adrenal extract and sprays of 



60 DISEASES 01 THE NOSE, THROAT AND EAR. 

menthol usually give relief. In exceptional cases the ostium must be 
enlarged, the middle turbinate removed, or puncture through the in- 
ferior meatus or the canine fossa must be done. In a small propor- 
tion of cases the products of inflammation are retained in the antrum 
and undergo caseation. All inflammatory symptoms may have sub- 
sided, but the decomposing pus emits a most offensive odor the real 
source of which may not be suspected. Removal of the pus by 
irrigation through the normal outlet or by an artificial opening 
dispels the fetor ( Avellis) . 

In looking for a cause of chronic empyema of the maxillary 
sinus it is necessary to make a careful examination both of the 
teeth and of the nasal chambers. It is still supposed that most 
of these cases may be traced to dental caries, but we have 
come to believe that a very large proportion owe their origin 
to a catarrhal inflammation affecting the middle turbinate and its 
neighborhood. Nevertheless, a tooth apparently sound at its crown 
maybe a source of mischief from a carious process going on at its root. 
Moreover, a septic infection maybe conveyed by the lymphatics from 
a point of decay in the crown of a tooth, the root of which is free 
from disease (Griinwald). M. H. Cryer. who has made careful 
study of this subject, believes that more teeth are lost from antral 
disease than primarily cause it, an opinion fully confirmed by E. S. 
Talbot, whose investigations have been exceptionably thorough and 
extensive. In other words, it is often necessary to seek a cause of 
antral empyema elsewhere than in the alveolus. It is sometimes pos- 
sible on anterior rhinoscopy to distinguish well-marked bulging 
toward the nasal fossa of the outer wall of the nose. There is likely 
to be some swelling of the face on the affected side together with 
sensitiveness on pressure or percussion. It has been claimed that 
dullness on percussion may detect a diseased sinus and succussion has 
been mentioned as a diagnostic sign, but it must require an excep- 
tionally keen ear to gain any data of value from either. In some 
cases, especially those of dental origin, the alveolus on the affected 
side is swollen, congested and sensitive to pressure. If any doubt 
remains as to diagnosis we may resort to exploratory puncture with 
a trocar, either through the inferior meatus, or the canine fossa. In 
the latter case an ordinary small-sized trocar and in the former the 
curved antrum trocar designed by Myles will be found convenient. 
This should be done with the strictest antiseptic precautions, lest a 



THE MAXILLARY SINUS. 



6l 



sound antrum be thereby infected (Fig. 35). Hydrogen dioxide in- 
jected into the antral cavity through the ostium as proposed by 
Moreau Brown, is relied upon to give its characteristic effervescence 
in the presence of pus, but should be used cautiously, since the rapid 
evolution of gas may produce painful distention. Pus may some- 
times be seen oozing from the antrum alongside a probe or canula 
passed through the ostium. With a Politzer bag attached to the 
canula, or air douche, one sometimes succeeds in expelling small 




Fig. 35. — Myles' Antrum Trocar, Canula and Washing Tube. 



quantities of pus that cannot be washed out by any process of irriga- 
tion. Secretion may sometimes be sucked out of an affected sinus 
by the process known as "negative politzerization" as recommended 
by Sestier. The suction method both for diagnosis and treatment 
has been elaborated by Sondermann and Spiess, who have devised 
special apparatus for the purpose. The diagnosis may be further 
confirmed by transillumination of the sinus by means of an electric 
lamp placed in the mouth (Fig. 36). It appears to have been first 
put to practical use by Addinell Hewson, of Philadelphia, and has 
more recently been investigated by Heryng and others. This test is 
more satisfactory in a room from which all other light is excluded. 
As proof of a clear antrum illumination of the face beneath the orbits 
is thought by Davidsohn to be less conclusive than that of the eves, 
which are usually bright in a normal skull. Exploratory puncture 
sometimes fails, owing to extreme density of the antral wall, which 
the trocar cannot penetrate, or to thickness of the pus whereby it 
is prevented from flowing through the canula. Transillumination 
demonstrates the presence of pus reliably, provided we eliminate 
certain sources of error, but under no circumstances should its 



62 



DISEASES OF THE NOSE, THROAT AND EAR. 



exclusive testimony be accepted as final. By examination with the 
fluorescent screen even more exact information may be gained 
than with the ordinary electric light in transillumination, but 
for this special expensive appliances are required. The investiga- 
tions of Zuckerkandl and others have shown that variations from 
the normal anatomical type are so frequent that we are liable to 
be led astray by certain abnormalities in the structure of the skull 





Fig. 36. — A, Heryng's Lamps for Transillumination; B, Meyrowitz' Electric Lamps. 

which alter the relations and dimensions of the sinuses. The remark- 
able diversity in the size of the antrum in different individuals is 
shown by the observations of Cattlin, quoted by Heath. It is larger 
in the male than in the female, it contracts in old age, while in very 
young subjects it is extremely small or entirely absent. He also 
notes the fact that subdivisions of the cavity by bony ridges and 
that extensions of the antrum into the malar bone, the alveolus, or 
posteriorly are far from infrequent. Perfect symmetry is practically 
unknown. It is easily seen, therefore, how the accuracy of the light 



THE MAXILLARY SINUS. 63 

test may be impaired. For instance, a relatively small antrum may 
transmit a deficient amount of light, as compared with the opposite 
side. A thickened lining membrane and anomalies in the bony wall 
of the antrum may interfere. The larger the antrum and the 
thinner its wall the more brilliant is the light test. Mucocele and 
cyst of the antrum are said to exaggerate the intensity of the light. 
In a case of the latter under my own observations this phenomenon 
was obvious in consequence of expansion of the antral cavity 
and attenuation of its anterior wall from pressure. Until the 
light test was employed this was supposed to be a solid tumor in 
consequence of its firmness on palpation. Dentary cysts become of 
special interest to the rhinologist only when they invade the nasal 
fossa, or, as in the foregoing case, the antrum. Unless the cystic for- 
mation begins at the very root of a tooth the swelling is more likely 
to present itself along the alveolus, obliterating the canine fossa 
and finally distending the jaw and perhaps the roof of the mouth. 
The contents, usually thin and clear, maybe reddish or coffee-colored, 
rarely resembling pus (F. C. Cobb). In the latter case, or if there 
is much inflammatory thickening of surrounding tissues, the light 
test may show more brilliancy on the sound side. The persistence 
of translucency in the presence of polypi is illustrated in a case 
reported, in which the antral cavity was filled with ordinary mucous 
polypi (Lambert Lack). In addition to the extent of the light area 
in the antral region, normally most intense just beneath the margin 
of the orbit, we may get more or less reliable information from the 
appearance of the pupils and from the presence or absence of per- 
ception of the flash of light on the part of the patient when his eyes 
are closed. In a large proportion of cases in which there is no antral 
anomaly the pupils are brightly illuminated and the patient is con- 
scious of a flash when the current is passed intermittingly. Having 
several times seen the light test frustrated by failure to remove a 
superior dental plate it seems not superfluous to call attention 
to the necessity of this precaution. The following instructive case 
from my clinic at the Manhattan Eye, Ear and Throat Hospital 
exemplifies an error into which we may be led even after the use of 
every diagnostic resource. 

A young man was admitted with a fluctuating tumor about the size of a 
hickory nut at the root of the left lateral incisor of the upper jaw, It had been 
in existence two months and was quite painless and insensitive. There was do 



64 DISEASES OF THE NOSE, THROAT AND EAR. 

history of nasal suppuration. Two years ago the jaw was injured by a fall in 
skating, and a carious tooth was subsequently extracted. Transillumination 
showed both sides of the face equally bright. "With an exploring needle passed 
through the alveolus creamy pus was withdrawn, and on free incision the abscess 
appeared to communicate with the antrum. In fact the case was pronounced 
by several an empyema of the antrum. But on more careful examination it 
was possible to demonstrate that a cavity existed above this abscess and was 
separated from it by a firm body wall, as proved by exploration with the probe 
and finger. The case was one of suppurating dentary cyst, a diagnosis further 
confirmed by the absence of symptoms pointing to the antrum as well as of pus 
discharge from the nasal passages. The abscess cavity slowly filled with 
granulation tissue and became obliterated, but it is easy to see how the antrum 
might have become infected as a result of excessive surgical zeal. 

The use of the tuning fork in differentiating a diseased from a 
healthy antrum has been proposed by D. A. Kuyk, but its practical 
value remains to be determined. The sound waves are said to be 
transmitted feebly if at all through a sinus occupied by fluid, being 
heard louder and longer through an empty antrum, even though of 
small size and enclosed by thick walls. 

The source of a nasal suppuration may be determined by plugging 
the orifices of the sinuses in succession by means of cotton or gauze 
and then observing when the flow is controlled (Griinwald). In 
view of the difficulty in locating the anatomical outlets of the various 
sinuses and of the frequent anomalies in their situation this proced- 
ure is not of very practical value. 

The fact must not be overlooked that even if pus is present in the 
antrum it may not have been generated there, since it has been 
proven that this cavity may act as a reservoir for pus formed in the 
frontal sinus or anterior ethmoidal cells. Examination is not com- 
plete until we have explored the other accessory cavities for the 
possible existence of suppuration in them. J. H. Bryan has de- 
scribed an example of direct communication of the frontal with the 
maxillary sinus, so that pus secreted in the former must inevitably 
have accumulated in the latter. He also quotes Fillebrown as having 
observed many cases in which the infundibulum ended below in a 
pocket so situated in front of the ostium maxillare as to direct a 
flow of pus from the frontal sinus into the antrum, the discharge not 
appearing in the nasal passage until the antrum and the abnormal 
infundibular pocket became filled. Probably some of the cases of 
"latent empyema" reported by Lichtwitz, Jeanty and others, re- 



THE MAXILLARY SINUS. 65 

markable for the absence of subjective symptoms, may be ex- 
plained by the existence of this anomaly. Obviously a diagnosis of 
suppuration originating in the maxillary antrum should not be 
hastily assumed. 

The diagnostic features upon which we rely offer an unmistakable 
picture. Some or all of them may be so feebly pronounced as to 
justify the term "latent empyema." 

The following are enumerated as the most trustworthy signs of 
chronic abscess of the antrum : 

1. Nasal suppuration. Pus is seen flowing from the middle 
meatus and it is sometimes possible to exclude the ethmoid cells and 
the frontal sinus as sources of the discharge. 

2. Pain, dull aching, or merely a feeling of tension in the antral 
region with more or less prominence of the face over the antrum and 
bulging inward of the wall of the nasal fossa. 

3. Swelling, redness and sensitiveness on pressure along the 
alveolus on the affected side. Carious, sensitive teeth may be found. 

4. Transillumination shows the suspected side in shadow, the 
pupil of the corresponding side is dark, and the patient himself sees 
less clearly or fails to see the flash of light with the eye of that side. 

5. Pus may be withdrawn from the cavity of the antrum by means 
of an aspirating trocar passed through the ostium,, the canine fossa, 
or the inferior nasal meatus. 

In many cases of chronic sinusitis the mental depression and 
general disturbance are out of proportion to the activity of the 
process going on within the antrum., Patients often complain of 
neuralgia, ill-defined headaches and lack of mental concentration 
which are almost incapacitating. It is possible to explain such con- 
ditions by supposing an impression upon the nerve centers from more 
or less absorption of suppurative products. At any rate it is usual 
to observe improvement in these particulars after free exit has been 
given to the discharge and pus formation begins to subside. 

The treatment of chronic empyema of the antrum should be con- 
ducted on general surgical principles; namely, the abscess must be 
thoroughly evacuated and cleansed of all diseased material. A 
carious tooth may protrude into the cavity, polypoid degenera- 
tion of the lining membrane, or necrosis of the bony wall may 
each share in perpetuating the suppurative process. Disease 
involving the ostium maxillare, either deflection of the septum, 
5 



66 DISEASES OF THE NOSE, THROAT AND EAR. 

nasal polypi, or enlargement of the middle turbinate in such a way 
as to interfere with drainage, must receive attention. A carious 
molar or bicuspid tooth should be extracted and the antral cavity 
entered along its socket. At the same time care should be taken to 
ensure a free opening of the anatomical outlet into the nose so as to 
give perfect through drainage. Sound teeth should never be 
sacrificed, but an opening may be made into the antrum through 
the canine fossa sufficiently large to admit a curette or even the 



OOO 



Fig. 37. — Myles' Antrum Tubes of Soft Rubber. 

finger for purpose of exploration. When the antrum is entered 
through the socket of a tooth or a small alveolar opening it 
is customary to introduce a tube of soft rubber, vulcanite or silver 
(Fig. 37), by which the cavity is drained and irrigated. Its outer 
aperture is usually provided with a plug for use during eating. 
The anterior end of the middle turbinate, if enlarged and obstructing 
the middle meatus, should be removed with a snare or forceps. 

Objection is sometimes made to opening the antrum through the 
mouth on the ground of danger of reinfection of the sinus from the 
buccal cavity. To obviate this the antrum may be entered by 




Fig. 38. — Mikulicz's Antrum Stilet. 

plunging a curved trocar, or the spear-pointed "stilet" of Mikulicz 
(Fig. 38), through the outer wall of the nasal fossa in the inferior 
meatus. Thus an aperture is made quite near the floor of the cavity. 
Sometimes the bone is so thick and dense as to be pierced with 
difficulty. A considerable portion of the wall of the meatus should 
be removed in order to keep the opening free. An argument against 
this method is that it gives us poor opportunity to explore the interior 
of the antrum. This is not strictly true, provided enough of the nasal 
wall is removed. It is to be preferred, however, because of the 



THE MAXILLARY SINUS. 67 

relief from buccal drainage and for the further advantage that 
passage of food from the mouth to the sinus cavity is avoided. 

In a small proportion of cases of empyema of the antrum the 
cavity can be entered and washed out through the natural opening. 
On the contrary, M. H. Cryer contends that it is impossible to enter 
the antrum through a normal ostium. In those cases in which 
we succeed in irrigating through the middle meatus the canula 
must have passed by an accessory opening. For this purpose a 
canula shaped somewhat like an Eustachian catheter, fitted with 
an ordinary piston syringe or rubber bulb, will be found convenient 
(Fig. 39). In seeking the opening in the antrum the canula should 




Fig. 39. — Hartmann's Canula. 

be introduced with the beak directed toward the concavity of the 
middle turbinate and passed well back into the middle meatus. 
It is then turned outward and drawn forward until its tip catches 
in the uncinate process, when by firm pressure upward and outward 
we sometimes succeed in entering the antral cavity. It may be 
necessary to remove the tip of the turbinate, or to correct a septal 
deformity, in order to introduce the canula (Fig. 40). 

The solution used for cleansing should be bland and unirritat- 
ing. A warm 2 per cent, boric acid or normal salt solution 
answers as well as any. An attempt to cure antral empyema 
by this means should not be persisted in too long, since failure to 
give relief in this way in from four to six weeks is certainly indica- 
tive of degenerative changes in the mucous membrane lining the 
antrum or of its wall, which require to be overcome by more radical 
methods. 



68 DISEASES OF THE NOSE, THROAT AXD EAR. 

The following case illustrates how a sinusitis may be kept up by retention 
of a foreign body. The patient was a lady about thirty years of age who 
had had a molar tooth extracted. Immediately after the operation the fluid 
used to cleanse the mouth was observed to escape from the right nostril, indi- 
cating that the tooth had. perforated the floor of the antrum. The aperture 
in the alveolus closed in a few days and an offensive purulent discharge from 
the nose appeared. About one year later the antrum was drilled through the 
canine fossa and irrigation practised for some weeks. The discharge ceased 
but recurred and the washings were resumed. The patient then went on very 
comfortably for a period of five years when she became rather run down in health, 
had frequent attacks of cold in the head and was, most of the time, conscious 
of an offensive odor in the nose. She suffered more or less from hemicrania and 




Fig. 40. — Snare Applied to Anterior End of Middle Turbinate. (Hajek.) 

a dull aching sensation in the region of the antrum. The anterior end of the 
middle turbinate was removed and the antrum was syringed through the 
ostium maxillare. The discharge gradually ceased and remained absent for a 
year when it recurred with all the original symptoms. The antrum was then 
opened freely by A. B. Duel when a calculous mass, the size of a small bean, 
was found lying in the cavity. On section this proved to be the fang of a 
tooth encrusted with salts. The antral opening was kept free for three or 
four weeks; when all discharge had ceased it was allowed to close. The cure 
seems to have been permanent. 

A similar case recorded by Macintyre is of interest especially from 
the fact that the foreign body, a lost drainage tube which had slipped 
into the antral cavity, was demonstrated with the X-rays. In doubt- 
ful cases the latter expedient may be of great value. 

Many operations differing in minor details have been suggested, 



THE MAXILLARY SINUS. 69 

but the main principles of all are to remove the cause of suppura- 
tion and provide a free outlet for pus. The latter indication is 
easily met; the former is effected by a course that allows complete 
examination of the antral cavity. 

A method which has been long in use is described as the Caldwell- 
Luc operation. The anterior wall of the antrum is exposed by an 
incision along the gingivo-labial fold of the upper jaw and the muco- 
periosteum reflected. The bony wall is then perforated by a drill 
or trephine and the opening enlarged with bone-cutting forceps, until 
it is possible to make a thorough inspection of the interior of the 
cavity. Thus, the existence of trabecular and of areas of polypoid 
degeneration, as well as necrosis which would otherwise escape 
observation, are detected. Should conditions of this kind be dis- 
covered the cutting forceps and curette must be used with freedom, 
after which the cavity is washed out with an antiseptic solution 
and packed with iodoform gauze. The gauze is removed at the 
expiration of twenty-four hours, and irrigation repeated daily until 
suppuration ceases. Gradual contraction of the opening takes 
place, and, as a rule, no measures are required to close it. After 
a time the irrigation may be entrusted to the patient who 
readily learns to manipulate the syringe used for washing. In 
addition to a muco-periosteal alveolar flap, Luc advocates the 
formation of a drainage opening in the inferior nasal meatus through 
which the end of the gauze packing is to be brought, with the inten- 
tion of closing the buccal wound by means of sutures. Practically, 
closure of the incision by stitching is found to be unnecessary. It is 
difficult to keep the wound perfectly aseptic and the stitches are apt 
to tear out or the wound to become infected. The parts unite 
readily if disturbance is avoided by care as to diet and movements 
of the mouth. 

Removal of the anterior end of the inferior turbinate body is rec- 
ommended as a first procedure with a view to making a large 
drainage opening 1 in the inferior meatus. Some operators prefer 
to postpone this step until the close in order to avoid annoyance from 
bleeding. The incision in the mouth is best made from the first 
molar tooth forward toward the frenum and should be extensive 
enough to give ample space for the use of the chisel or trephine. 
At the moment of incising the lining membrane of the antrum free 
hemorrhage often occurs. It may be readily controlled by turn 



70 DISEASES OF THE NOSE, THROAT AND EAR. 

pressure for a few moments with iodoform gauze. It is said to be 
modified by the preliminary injection of cocaine and suprarenal 
extract solution. 

Failures in the radical operation may result from overlooking the 
existence of areas of polypoid degeneration, or bony septa, which 
partially, or completely, subdivide the antral cavity. In a case 
of my own a firm bony partition divided a very large antrum by 
projecting from its floor nearly to its roof. Without care and 
thorough exposure of the parts it might easily have escaped observa- 
tion. The case referred to is also interesting as illustrating the 
condition of so-called "latent empyema" in which the symptoms 
were so obscure that a positive diagnosis of sinus suppuration was 
very tardily accepted. 

The opening in the nasal fossa through the inferior meatus should 
be large enough to obviate the danger of premature closure. It is 
thus possible to dispense quite early with drainage tubes and gauze 
dressings, a very desirable object, since it is believed that many cases 
of antral suppuration are kept up by too energetic postoperative 
meddling. 

In some cases of chronic antral disease the transillumination test 
shows the absence of pus immediately after operation. In most of 
them, however, the changes in the bony wall and mucous lining are 
so extensive that the light is not transmitted for several weeks, and 
possibly, not at all. This fact is noted by DeRoaldes, every one of a 
series of cases operated upon by Gordon King and himself showed 
opacity after a cure of the empyema had been pronounced. 

The use of astringent applications to the interior of the cavity 
during convalescence is sometimes required. As a rule, simple 
cleansing by means of antiseptic irrigation is all that is necessary. 
Sometimes a solution of chloride of zinc, 20 per cent., or protargol 
solution, ten grains to the ounce, seems to assist in arresting the sup- 
purative process. In others, the formation of pus ceases almost at 
once and, in from four to six weeks, a cure is established. 

The dry treatment of sinus suppuration by insufflation with 
various powders, is practised with success by many. A mixture of 
aristol and boric acid powder is recommended by Myles, who is an 
adherent of the intranasal route to the antrum except when dead 
bone or neoplastic growth is present. The inferior turbinate is 
pushed aside or enough of it is resected to give free access to the 



THE FRONTAL SINUS. 7 1 

thinnest part of the nasal wall of the antrum. The structures to be 
avoided are the nasal duct at the anterior end of the inferior turbi- 
nate and the posterior palatine canal containing the great palatine 
nerve and vessels. Enough of the antral wall is removed to permit 
the use of a curette and the introduction of gauze packing to be 
removed in forty-eight hours. As a precaution against recurrence 
attention should be given to the condition of the nasa] membranes 
and to the removal of any obstacle from the region of the antral 
orifice. It is impossible to emphasize too strongly the importance 
of this point, as well as the avoidance of meddlesome interference 
with a reparative process by excessive irrigation with strong solu- 
tions, or by plugging the antral cavity with sterilized or medicated 
gauze for too long a period. 

In most cases an alveolar opening into the antrum gradually con- 
tracts. Occasionally its closure has to be encouraged by cauteriza- 
tion. In exceptional cases a permanent fistula remains, and it has 
been my experience to see several such cases in which the condition 
caused little or no inconvenience. The continuance of discharge 
after operation is explained by complications which have already 
been adverted to, namely, the persistence of pyogenic membrane in a 
pocket or adventitious sinus overlooked at the time of operation, 
or the presence of some neglected nasal anomaly, or finally the fact 
that the antrum is acting as a receptacle for pus overflowing from the 
frontal sinus or the ethmoidal cells. Moreover, the influence of the 
general health upon a suppurative process should be remembered, 
and if indicated measures tending to improvement in that direction 
should be adopted. 

FRONTAL SINUS. 

Inflammation of the frontal sinus is a frequent complication of 
an acute coryza and is prone to lapse into a chronic condition in the 
presence of any occlusion of the hiatus frontalis. One of the earliest 
symptoms in acute cases is pain in the supraorbital region on the 
affected side. In a small proportion of cases there is but one frontal 
sinus, no median septum being present (Fig. 41). An exceedingly 
rare condition has been described by Suarez de Mendoza, in which 
two sinuses on either side, one behind the other, were found. They 
communicated by small openings with each other and each opened 



72 



DISEASES OF THE NOSE, THROAT AND EAR. 



into the nose by a separate passage. Such an anomaly might render 
its possessor more prone to sinus disease, and it is easily seen that 
any therapeutic measures, surgical or other, are thereby made more 
difficult and complicated. Pain may be intense, neuralgic in 
character, aggravated by blowing the nose, or a stooping position, or 
it may consist of simply an aching sensation, or a sense of dullness or 
weight. There is marked tenderness along the supraorbital ridge 
and especially on deep pressure under the supraorbital arch. Fre- 
quently there are puffiness and swelling of the skin over the affected 




Fig. 41. — Normal Frontal Sinuses of Average Size. (Logan Turner.) 



sinus and of the upper eyelid, and sometimes slight pitting under 
compression. These symptoms subside with the occurrence of a 
purulent nasal discharge, or distention of the cavity may be followed 
by exophthalmos and formation of an orbital abscess. 

The diagnosis based on the foregoing symptoms is usually free 
from difficulty. Transillumination offers a less reliable diagnostic 
sign in case of the frontal sinus than with the antrum owing to the 
well-known fact that asymmetry of the former is much more frequent 
(Fig. 42). A small electric lamp, covered except at its end by an 
opaque shield, pressed well under the supraorbital arch, defines 
the boundaries of the frontal sinus quite accurately. By using a 
lamp on either side simultaneously, or a double transluminator like 
that devised by H. S. Birkett, it is possible to compare the sinuses 



THE FRONTAL SINUS. 



73 



by illuminating both at the same moment. Thus the rays of light 
are thrown upward through the floor of the sinus. The single lamp 
being placed at various points on the forehead, meanwhile the 
patient being directed to keep his eyes closed, he himself can map 
out the sinuses with considerable precision by noticing when the 
light becomes perceptible as it is shifted about. By what they call 
"medio-frontal" illumination, Lubet-Barbon and Furet have 
demonstrated that by placing the lamp in the median line of the 
forehead a difference in intensity of the light may be observed under 



M 






" 





Fig. 42. — Asymmetry of Frontal Sinus. 
a, Right sinus almost obliterated and left subdivided by numerous septa; b, small 
right and very large left sinus. (Logan Turner.) 



the supraorbital arch. Logan Turner, whose researches in this 
field have been very complete, finds many interesting anomalies and 
variations in the frontal sinuses and concludes that the light test is 
of little or no practical value in chronic suppuration in these cavities, 
his view being based on the following grounds: " (1) One or both 
sinuses may be absent, and when this anatomical condition exists, 
there is opacity on one or both sides of the skull. (2) A certain 
proportion of healthy sinuses fail to illuminate; this may occur on 
one or on both sides of the skull. (3) A sinus on one side of the 
skull may illuminate with less brilliancy than its fellow, although 



74 



DISEASES OF THE NOSE. THROAT AND EAR. 



both are perfectly normal. 4) Many sinuses containing pus. and 
with their mucous membrane thickened and often polypoid, illumi- 
nate with considerable intensity." Darkness may indicate no 
sinus, a thick walled sinus, or a diseased sinus, so that in most cases 
we must arrive at a diagnosis by other means. The absence of 
subjective symptoms may necessitate reaching an opinion by ex- 
clusion. If pus quickly reappears in the middle meatus, the antrum 
having been emptied of purulent contents by syringing through the 




Fig. 43. — Septa of Frontal and Sphenoidal Sinuses. (SchadJe.) 



ostium and the patient's head being held quite erect, the source of 
pus must be either the frontal sinus or the anterior ethmoidal cells. 
Even in so-called "latent" cases a certain degree of tenderness on 
the affected side is elicited by firm pressure upward against the floor 
of the sinus. In cases of the latter class also there is apt to be at 
times more or less external swelling in the region of the sinus. In 
some cases a positive diagnosis can be made only by catheterizing 
the sinus through the frontonasal canal with a Hartmann or Krause 



THE FRONTAL SINUS. 75 

canula, a feat often very difficult of accomplishment. The passage 
may be tortuous, or it may be necessary to resect the anterior end of 
the middle turbinate or other obstacle before a probe or canula can 
be passed. The end of the probe may become engaged in an ante- 
rior or fronto-ethmoidal cell, or may be arrested by an irregularity in 
the canal, but if it seems to have some freedom of movement and 
has passed a distance of not less than six or seven centimeters from 
the floor of the nose the presumption is that it has entered the sinus 

(Fig. 43)- 

The experiments of Onodi, Coakley, Mosher and others show 
that skiagraphy gives most valuable information as to dimensions 
of the sinuses. The existence of septa, recesses, and somewhat less 
clearly of inflammatory products may be demonstrated. 

In the treatment of a frontal empyema the first essential is the cor- 
rection of any lesion or obstruction in the nostril. The tendency 
to spontaneous cure is certainly more pronounced than with the 
other accessory sinuses provided drainage through the anatomical 
outlet can be restored. If the case is allowed to pursue its own 
course discharge of the abscess may take place into the middle 
meatus through the frontonasal canal, or it may rupture into the orbit 
where the wall of the sinus is thinnest, outward through the external 
table, or through the inner table into the cerebral cavity. In a case 
of long standing which occurred in my own clinic the abscess pointed 
at the outer limit of the superciliary ridge; in the meantime by 
pressure upon the eyeball producing symptoms which had led the 
patient to consult an oculist. The abscess was opened by free in- 
cision when the nature of the case was demonstrated. The best 
method of treating a chronic frontal sinusitis is by external operation 
which leaves more or less of a scar but gives reasonable assurance of 
cure. In attempting the relief of the case through the nose we are 
handicapped by being obliged to work in a very narrow passage and, 
moreover, opportunity is not given to make proper exploration of the 
sinus cavity. Indeed it is difficult to enter the sinus by passing a 
probe along the frontonasal ductr One is quite as likely to get into 
the anterior, or fronto-ethmoidal cells, or even altogether fail to 
find the orifice of a canal. The latter has been the experience of 
more than one operator after complete extirpation of the middle 
turbinate body. Great assistance may be derived from the A'-ray 
both in guiding the probe and in directing the drill in enlarging 



76 DISEASES OF THE NOSE, THROAT AND EAR. 

the nasofrontal duct. According to Spiess the diameter of the drill 
should not exceed three millimeters. An additional safeguard is 
provided in the "pilot burr" of Ingals, an instrument intended to 
prevent deviation of the drill from its proper channel. This 
authority, who is a most confident advocate of the endonasal route, 
has had excellent results. While the dangers of attempting to enter 
the sinus through the nasal fossa may be eliminated by his method it 
would seem impossible to reach all the foci of suppuration in an 
irregular sinus or one complicated by an ethmoiditis. It must be 
admitted also that a perfect cure is not always attainable by a 
so-called radical external operation. Symptoms due to tension 
from pent-up secretions are relieved but suppuration does not cease. 
At the present time the conclusion seems to be justified that only 
simple uncomplicated cases are suitable for the endonasal operation. 
Doubtful cases of multiple sinusitis of long duration are likely to 
yield if at all to a mode of attack that allows removal of all diseased 
tissue as well as gives free drainage. 

In most cases the lining membrane has undergone a degenerative 
process which necessitates thorough curettage, or caries or necrosis 
of bone may have taken place. Under such circumstances simple 
drainage is not sufficient to accomplish a cure and the only rational 
mode of treatment is to make free exposure of the cavity by what is 
known as the Ogston operation, or one of its modifications. As carried 
out by Luc it is thought to be especially appropriate for an empyema 
comparatively recent, in a sinus of medium size and not complicated 
by ethmoidal disease. An incision is made from the supraorbital 
notch toward the middle line, including the skin and periosteum, 
wh ch are then reflected and the anterior wall of the sinus is opened 
by means of a trephine, hand, drill, or chisel. If more room is needed 
a vertical incision is made in the median line at an angle with the 
first. Sufficient bone should be removed by means of cutting 
forceps to enable one to explore the walls of the cavity thoroughly and 
to pass a drainage tube through the frontonasal duct into the nasal 
fossa. The cavity having been thoroughly cleansed and irrigated, 
the external wound is closed with sutures, a drainage tube being 
passed through the nasal opening. So long as signs of suppuration 
appear with the irrigating fluid used for washing the cavity the tube 
should be retained. Usually in the course of a week or ten days it 
may be safely withdrawn. 



THE FRONTAL SINUS. 77 

Various modifications of the original operation for frontal sinus 
disease as proposed by Ogston have been suggested. Removal 
of the anterior wall and of more or less of the floor of the sinus, as 
in the operation performed by Kuhnt, gives an excellent exposure 
and the cavity at length becomes filled with granulation tissue and 
orbital fat. As in all operations involving the floor of the sinus 
derangement of the eye may follow, but it is usually temporary. 
Diplopia from disturbance of the pulley of the superior oblique 
and iritis are the most common. The former is avoidable and 
the latter may be prevented by the use of atropin. By this method 
the ethmoid labyrinth is brought within reach and trabecular and 
diverticula of the sinus are much less likely to be overlooked, but 
the resulting deformity is certainly greater. A liberal opening 
is made into the nasal fossa and the external wound is completely 
closed. Nevertheless, the wound may become infected and fail 
to unite, and in consequence an ugly retracting scar results. In 
contrast with the foregoing is the "open" operation advocated by 
Curtis and Coakley, in which an attempt is made to shut off the 
nasal cavity and drainage is effected by way of the forehead wound. 
A sinus of moderate size is thus finally obliterated. Various 
expedients have been suggested to prevent or correct disfigurement. 
In a modification proposed by R. W. Payne, several openings are 
made into the affected sinus, intermediate bridges of bone being 
left to serve as a supporting framework to the soft parts. The 
insertion of a plate of aluminum, platinum, decalcified bone, or 
ivory to lessen the disfigurement has been suggested by Semon. 
Paraffin prosthesis is likely to prove useful in this direction. A most 
excellent result was thus obtained by Curtis who dissected out a dis- 
figuring operative scar and sutured the wound over a mass of paraffin 
("paraffin cast") entirely filling the sinus cavity. It remains to be 
seen whether such a large amount of paraffin will permanently retain 
its shape. 

The following method of operating is described by Lothrop (Tig. 
44). A curved incision is made from near the nasofrontal suture 
upward parallel with the folds of the skin formed by the corrugate* 
supercilii muscle for about fifteen millimeters, gradually curving 
outward and following the horizontal folds. With a drill or 
trephine an opening is made at the inner angle of the orbit and 
below the inner extremity of the superciliary ridge. According 



78 



DISEASES OF THE NOSE, THROAT AND EAR. 



to Lothrop the existence of a diploe in this situation may be relied 
upon to show the absence of a frontal sinus, and none being found 
pus, if present, must come from the ethmoid cells. In several 
instances to the author's knowledge both cancellated tissue and 
sinus have been absent. In one hundred crania examined by Max 
Scheier the frontal sinus was absent five times, and other anomalies 
were frequent. 




Fig. 44. — Incisions in Opening Frontal Sinus* {Lothrop.) 
1, Anterior wall. Osteoplastic operation, the bone flap thus formed is deflected down- 
ward. 2, Floor, giving access also to ethmoidal cells. 

Through the opening thus formed the cavity is probed to deter- 
mine its dimensions and possible changes in its mucous lining. If 
the sinus is found to be very spacious, the opening must be enlarged 
by chiseling a bone flap along the line of incision with the supra- 
orbital arch serving as a base. This bone flap may readily be pried 
downward and fractured along the thin orbital wall of the sinus 
and is to be replaced at the conclusion of the operation. The advan- 



THE FRONTAL SINUS. 79 

tages claimed for this method are that the sinus may be well opened 
and that a large opening may be made into the nasal fossa without 
disturbing the orbit. Several other osteoplastic operations with 
a similar end in view have been offered. In that of Hajek, the bone 
flap is formed from the anterior wall and reflected upward. In an 
operation recently described by J. C. Beck a skin flap is reflected 
from below upward. The dimensions of the sinus having been 
accurately defined by a celluloid tracing of a radiogram, a bone 
flap is made to conform strictly with the outline of the celluloid 
model. The bone is penetrated above sufficiently to admit a Gigli 
saw directed downward to the level of the supraorbital ridge. 
The osteoperiosteal flap thus formed is everted downward to the 
bridge of the nose completely exposing the interior of the sinus. 
Free nasal drainage is provided for by enlarging the nasofrontal 
duct and removing the anterior ethmoidal cells. The parts having 
been replaced the external wound is sealed. This is called a " con- 
servative" operation by its author, perhaps because he prohibits 
the free use of the curette, although he removes diseased mucous 
membrane. All these methods are open to the objection that the 
sinus is more or less liable to reinfection, since it has not been effaced. 

The frontal sinus may also be entered through its inferior wall, 
giving a less perfect exposure of the cavity but rendering the eth- 
moid cells accessible and being followed by somewhat less deformity. 
Without the exercise of great care there is, however, more danger 
of disturbing the orbit or interfering with the lachrymal apparatus. 
This is sometimes known as Jansen's operation. The objection to 
it last mentioned is very serious while it is by no means absolutely 
free from disfiguring effects. 

In this operation the incision commences opposite the inner can- 
thus, in front of the margin of the orbit, over the nasal process of 
the superior maxilla. It curves upward and outward along the 
eyebrow to the supraorbital notch. The periosteum is elevated and 
the flap turned down so as to expose the internal angular process 
of the frontal bone. Hemorrhage may occur from the supraorbital 
and angular arteries and may be controlled by pressure or by liga- 
ture. The bony wall of the sinus is opened by means of the chisel 
just above the internal angular process of the frontal bone where 
the bone is thinner than on the anterior surface and more easily per- 
forated. If pus escapes through the operative wound at once we 



80 DISEASES OF THE NOSE, THROAT AND EAR. 

have reason to believe that the frontal sinus is affected; if not, 
the presumption is that suppuration arises from the ethmoid cells 
which may be easily reached through this wound. The most im- 
portant step in these operations is the establishment of roomy com- 
munication with the nasal fossa by removal of the anterior ethmoid 
cells. A small probe is passed through the ostium into the nose to 
be used as a guide. The finger may be introduced into the nostril 
in order to give the curette the right direction, which should be 
downward and somewhat backward. Practically, this consists in 
removal of a greater part of the lateral mass of the ethmoid which 
fills in the meatus frontalis and, if thorough, no drainage tube will 
be required. The external wound is closed completely and pro- 
tected with a sterile dressing and the nostril is packed with iodoform 
gauze for twenty-four hours. 

In the after-treatment irrigation of the nasal fossa should be 
gentle so as to avoid disturbing the wound in the skin and should 
be limited to a warm 2 per cent, boric acid solution. The patient 
should be especially warned not to blow the nose until the wound 
is thoroughly healed. 

Sometimes the external wound fails to unite completely, especially 
in cases of extensive disease of the sinus or of bone involvement. As 
a rule, however, union takes place kindly and the relief of symptoms 
attributable to pressure is almost immediate. 

The most extensive and radical operation now in vogue on the 
frontal sinus is that planned by Killian. But few dissent from the 
opinion that it is the best for large sinuses and complicated cases, 
while its promoter claims that it is suited to all cases of frontal 
empyema. The anterior wall and floor of the sinus and the frontal 
process of the superior maxilla are removed leaving a supporting 
bridge of bone along the supraorbital margin. Thus the entire 
cavity and the ethmoid cells are well laid open and it is hardly 
possible to miss a focus of suppuration. The skin incision extends 
from the temporal end of the eyebrow to the root of the nose, thence 
curving downward to the base of the nasal bone. The osseous 
bridge is outlined by one incision through the periosteum corre- 
sponding with that in the skin and a second, the skin alone having 
been raised, parallel with and 5 to 6 cm. above the first. Above 
the latter the bone is well bared of skin and periosteum to the limits 
of the sinus, which is then opened near the median line. Great 



THE FRONTAL SINUS. 8 1 

stress is laid by Freudenthal upon the importance of entering the 
sinus below the bridge near the inner canthus rather than on the 
forehead. Several cases have been reported in which the operator 
was misled as to the dimensions of the sinus, but the accurate outline 
apparently given by the skiagraph should protect us from the 
danger of opening the cranial fossa. The frontal process and the 
floor seem to be most easily reached by stripping up the soft parts 
through the line of the lower periosteal incision. In this region 
great care must be taken to avoid damage to the eye. The chisel, 
Hartmann's forceps, and in the ethmoid region Volkmann's spoon are 
the instruments preferred for attacking the bone. The operative 
field is prepared by thorough washing with alcohol and an antiseptic 
solution, but it is not thought necessary to shave the eyebrow. The 
posterior nares are plugged until it becomes evident that the eth- 
moid cells must be extirpated. All morbid tissues having been 
removed, the parts are irrigated with warm saline solution and the 
external wound carefully sutured. A drainage tube is carried from 
the outer end of the external incision to the anterior naris and held in 
place by a nasal tampon which at the same time supports the flap 
of mucous membrane which covered the middle turbinate bone, in 
case that structure has been removed together with the ethmoid 
cells. The dressings are changed daily and the tube dispensed with 
after the third or fourth day. No irrigation or flushing of the nasal 
cavity is permitted and the patient is forbidden to blow the nose. 
The external dressings consist of a light gauze pad over the eye, in 
which, as a precaution against iritis, atropin has been instilled, and a 
firm bandage to the forehead to keep the scalp in contact with the 
posterior wall of the sinus (Luc) . It is advisable to bevel the bone 
at the upper margin of the wound so that the skin flap may be 
adjusted smoothly. The weak point lies behind the inner end of the 
supraorbital bridge where secretion may persist and collect unless 
ample drainage space is provided in the frontonasal region (Logan 
Turner). In view, of the comparative infrequency of ethmoid 
disease as a complication of frontal empyema, i.e., 62 per cent, 
according to Turner's statistics, the need of general resort to this 
rather formidable procedure is in doubt. Yet it must be admitted 
that the mortality and the calls for secondary operation have 
been less frequent with the obliterative than with other methods of 
operating. 
6 



52 DISEASES OF THE NOSE, THROAT AND EAR. 

The question as to whether a radical external operation should 
be advised in a given case is not always easy to answer. By no 
means every case thus handled gets well, if by that we mean abso- 
lute cessation of pus discharge. On the other hand, the ap- 
pearance of pus in the middle meatus known to proceed from the 
frontal sinus is far from being an indication for immediate external 
operation. Continued difficulty in concentrating the mind, constant 
headache associated with frontal suppuration and more or less nasal 
obstruction may be accepted as indications for radical interference, 
in case intranasal methods have already failed, and provided the 
patient is willing to submit to probable disfigurement and at the 
same time take the chance of incomplete relief. Post-operative 
fatalities have been numerous enough to show that details of technic 
have not yet been perfected, and place this surgical procedure in the 
list of capital operations which should not be undertaken without 
due consideration. 

ETHMOID CELLS. 

Almost every writer on the subject has his own arrangement of 
the morbid conditions affecting the ethmoid region, based either 
on a pathological hypothesis or on clinical history. Most of the 
former are more or less erroneous while the latter are apt to be con- 
fusingly elaborate. In view of the frequency of ethmoid disease it is 
rather surprising that such extreme difference of opinion should 
prevail as to its origin and nature. Bosworth regards ethmoiditis 
as the most common form of sinus inflammation, while the post- 
mortem records of Lapalle show the occurrence of ethmoidal 
empyema only six times, frontal five, sphenoidal nineteen and 
maxillary forty-eight times in fifty-five cases of sinus disease. In 
every instance empyema of other sinuses coexisted — the maxillary 
five times, the sphenoidal four times and the frontal twice. An 
ethmoiditis may be latent, that is, it is disclosed by no well-defined 
objective symptoms, or it may be attended by free pus discharge 
the source of which is obvious. It may be obscured by the concur- 
rence of mucous polypi, not only in the nasal fossae but even within 
the cells, and by orbital abscess. The latter complication is cer- 
tainly very infrequent in this country. The middle turbinate bone 
may be in a state of bulbous or cystic expansion {concha bullosa), 



THE ETHMOIDAL CELLS. 83 

the ethmoid cells being enormously distended, and their bony walls 
fragile and more or less carious. Spiculae of bone are found in the 
discharges and the existence of necrosis may be determined by 
exploration with the probe or the finger. Empyema of the ethmoid 
cells occurs without regard to sex or age. Cases of orbital abscess 
have been reported as a rule in young subjects. 

The causative relations of ethmoiditis and of sinus disease in gen- 
eral to atrophic rhinitis, or "ozena," as some writers persist in call- 
ing it, a theory especially advocated by Griinwald, and to nasal 
polypi have been fertile topics of debate. Bresgen found empyema 
of the maxillary sinus or of the ethmoid cells in eleven cases of 
atrophic rhinitis, Moure in 32 out of 114 cases, while Jacques and 
George firmly maintain the causative relation of sinus disease to 
atrophy and assert that implication of the sphenoidal sinus and 
ethmoid cells most frequently preexists. The relation of sinus 
disease to nasal polypi will be discussed at length in the chapter 
relating to the latter. 

A rather rare condition of some interest but fortunately not of 
very serious import — emphysema of the eyelid — has been described 
by Beaman Douglass. It maj occur as a result of disease of the 
ethmoid cells or of injury to them in operating. As a consequence 
of violent blowing of the nose after a laceration of the lachrymal 
duct or of a compound fracture of the nasal bones it does not concern 
us in this connection. The upper lid rather than the lower is invaded, 
the air rinding its way from the ethmoid cells through the wall of the 
orbit and forward along the fascia which separates the extrinsic 
muscles of the eyeball from the intrinsic. The accident is indicated 
by the occurrence of sharp pain in the orbital region, immediate 
swelling of the lid and more or less displacement or protrusion of 
the eyeball. Usually the air is absorbed and the parts resume 
their normal appearance in a few days with the exception perhaps of 
some degree of ecchymosis. With a view to avoiding this accident 
the use of a small blunt- edged forceps instead of a curette in the 
ethmoid region is recommended as being less likely to perforate 
the lamina papyracea. 

Inflammation of the ethmoid cells may be catarrhal or suppura- 
tive. The former often accompanies an acute rhinitis and subsides 
as the latter disappears, or may degenerate into a purulent process. 

Suppuration of the ethmoid cells may be acute or chronic, the 



84 DISEASES OF THE XOSE, THROAT AND EAR. 

former owing to the anatomical construction of the parts tending 
to develop into the latter. In some cases the only symptom is 
a discharge of pus from the nostril. If the anterior group of cells 
only, or the fronto-ethmoid cells, is affected pus appears in the middle 
meatus; if the posterior group is diseased pus spreads over the 
septal surface of the middle turbinate body and finds its way back- 
ward to the nasopharynx. The tendency to spontaneous recovery 
is slight in ethmoid disease and in addition to the pus discharge 
certain other symptoms are characteristic. Pain is usually deep 
seated and is frequently referred to the bridge of the nose or the 
postorbital region. Occasionally mixed with the pus bits of carious 
bone are detected. When the bone is affected crepitation is some- 
times elicited by firm pressure at the inner angle of the orbit. Even 
in the absence of pus there is a peculiar sickening odor, and when 
necrosis is in progress there is added the characteristic necrotic 
odor. There may be ocular disturbance, exophthalmos and 
contraction of the visual field from pressure upon the orbit, and 
where there is a great deal of intracellular mischief much distress 
may result from distention of the ethmoid cells and intranasal pres- 
sure. The sense of smell is more or less impaired or perverted, 
the patient himself complaining of kahosmia. Indications of septic 
infection may be exhibitea in febrile reaction and general systemic 
depression. In aggravated cases symptoms of meningitis develop. 
In fortunate cases the pus is discharged into the nasal chamber; in 
others, it may open at the inner angle of the orbit. It may reach the 
antrum or frontal sinus or, in its worst phase, it may penetrate the 
anterior cerebral fossa and induce a fatal meningitis 

A diagnosis must often be reached by exclusion. In cases in which 
the foregoing symptoms are pronounced there should be no difficulty 
in defining the condition; but in others the symptoms are so obscure 
as to leave the case a long time in doubt. 

A serious prognosis must be given unless free intranasal drainage 
is established. Fortunately this is usually feasible, but while pus 
formation is active the patient is not absolutely out of danger. 
Kuhnt has recorded seventeen cases of fatal meningitis consecutive 
to sinus disease, a number large enough to serve as a warning against 
neglect of this condition. 

Treatment, in cases of moderate severity, consists in free opening 
of the ethmoid cells through the nostril by means of cutting forceps, 



f.n 



THE ETHMOIDAL CELLS. 



drill or curette and the subsequent thorough cleansing of the parts 
with an antiseptic solution (Fig. 45). A nasal deformity which 
interferes with drainage should be corrected. The possibility of other 
sinuses being involved should not be overlooked. Complication of 
the case by the existence of nasal polyps is very frequent and they, 




Fig. 45. — a, Hajek's double curette; b, c, Grumvald's cutting forceps. 

as well as excessive granulation tissue and necrotic bone, should be 
removed. These operative procedures upon the ethmoid are usually 
done under local anesthesia with cocaine. Careful examination with 
the probe for the detection of spicukr of bone should be practised 
and the case be kept under close watch as long as suppuration 
continues. 



86 DISEASES OF THE NOSE. THROAT AXD EAR. 

The anterior ethmoidal cells are situated in the upper part of the 
ethmoid and fill in the floor of the frontal sinus. Most of them are 
large and many have their walls completed by articulation with 
neighboring bones. They are very numerous and suppuration in- 
volving them is liable to be transmitted to the frontal sinus. 

Such being the case the operation which has just been described 
is applicable only to disease limited in extent and in an unusually 
wide nasal chamber. In cases of long standing nearly all the 
ethmoid cells are involved and a very large portion of them are 
quite inaccessible through the nasal fossa. In attempting to 
curette the field of operation is almost immediately obscured by 
hemorrhage, so that we run the risk of carrying our instrument in 
an improper direction or too far. thus either invading the orbital 
cavity or possibly perforating the cribriform plate and entering the 
cerebral fossa itself. About all that can be done by the nasal method 
of treating ethmoiditis is to remove the middle turbinate including 
the cell which sometimes exists in its body and curette the cells in 
its immediate neighborhood. When relief is not obtained by this 
means an external operation is the only safe and radical mode of 
treatment. An external incision along the inner angle of the orbital 
ridge at the level of that practised for opening the frontal sinus 
is recommended. By this incision the floor of the frontal sinus is 
exposed and the ethmoidal region is brought within easy reach. 
All the cells can be thoroughly curetted and an opening made into 
the nasal cavitv for drainage, so larse that no drainage tube is re- 
quired. If necessary the posterior group of cells may also be at- 
tacked by this route. The external wound, after thorough cleansing 
and sterilizing of the cavity, is closed as in the operation for frontal 
sinus disease. Usually the wound heals without much disfigure- 
ment, provided it be carefully sutured and nasal drainage be ade- 
quate. Care should be taken in irrigating the nasal fossa to use no 
violence in order that the wound may not be disturbed. 

The more formidable operation just described is called for very 
exceptionally. In the majority of cases the patient will be content 
with the relief given by opening and draining the cells through the 
nose, even though the disease cannot be thus completely suppressed. 



THE SPHENOIDAL SINUS. 



87 



SPHENOIDAL SINUS. 

Inflammation of the sphenoidal sinus is less rare than has 
been hitherto supposed. The causes acting to produce disease 
here are similar to those that prevail with reference to the other 




Fig. 46. — Probe in Orifice of Sphenoidal Sinus Showing Distance from Nasal Vestibule, 
about 21/2 inches. (Bryan.) 
Sieur and Jacob profess to be able to catheterize the sphenoidal ostium by passing 
a curved instrument close to the dorsum of the nose and the under surface of the crib- 
riform plate, instead of going obliquely across the middle turbinate. 

sinuses, and the pathological changes resemble those occurring 
elsewhere. The opening of the sphenoidal sinus is so situated as to 



DISEASES OF THE NOSE. THROAT AXD EAR. 

impede the free escape of secretion. It may sometimes be found by 
passing a probe obliquely upward "across the middle turbinate body 
and close to the septum (Tig. 46). The pus secreted in sphenoidal 
sinusitis usually flows backward into the pharynx or spreads over 
the posterior end of the inferior and middle turbinates. Xo doubt 
many cases of so-called postnasal catarrh are really examples of 
sphenoidal inflammation. The pain often referred to the occiput 
is of an aching character and may be intense and radiating. Ocular 
symptoms are very apt to develop in sphenoidal disease from 
involvement of the trigeminus. Impairment or loss of sight and 
exophthalmos have been observed. In a case under my own care 
marked ptosis was a prominent symptom which disappeared as 
the inflammatory signs subsided. I: is seldom possible by rhinos- 
copy, either anterior or posterior, to determine definitely the origin 
of the pus: that is. it cannot be seen actually flowing from the sinus 
except in certain cases of atrophy or deviated septum. In general 
pus from the sphenoidal sinus inclines to spread out over the vault 
of the pharynx. It may be impossible to tell whether the discharge 
comes from the sphenoidal sinus or the pharyngeal bursa, suppura- 
tion of which, under the name of Tornwaldt's disease, is occasionally 
observed. 

The prognosis in sphenoidal sinusitis is less favorable than that 
of inflammation of other sinuses owing to the difficulty of reaching 
the cavity. Extension of the disease to the orbit or meninges may 
occur with fatal results. A case of erosion of the cavernous sinus 
and fatal hemorrhage has been reported and others of thrombosis 
involving the circular and cavernous sinuses and the ophthalmic 
veins have been recorded. An extraordinary case in which the 
whole body of the sphenoid was extruded, the patient recovering, 
was reported many years ago by Baratoux. 

In the treatment of sphenoidal sinusitis the most important indi- 
cation is early and free opening so as to permit the removal of 
necrosed bone, if any exists, and thorough drainage of the cavity. 
The drill or trocar is introduced in the direction indicated for dis- 
covering the anatomical outlet of the cavity, namely, obliquely 
upward across the middle turbinate body. The distance of the 
anterior wall from the tip of the nose in the adult varies from three to 
three and three-fourths inches: the average depth of the sinus is 
about a half-inch, but the investigations of Onodi and manv others 



THE SPHENOIDAL SINUS. 89 

have shown irregularities to be so frequent that these measurements 
must not be accepted as absolutely reliable. When drainage is once 
well established and the parts kept aseptic by thorough cleansing, 
recovery may be expected. 

In an elaborate study of the sphenoid by Beaman Douglass at- 
tention is directed to the existence in the smaller sphenoidal wings 
of supplementary cells originally described by Zuckerkandl and 
Hajek. Their surgical importance is considerable in connection 
with an inflammation involving either the sphenoidal sinus or the 
posterior ethmoidal cells. In some cases the main sphenoidal sinus 
has been found to extend partly or completely into the wing of the 
bone. In others the sinus in the. wing is quite independent and 
opens by its own passage into a posterior ethmoidal cell or into the 
recessus spheno-ethmoidalis. In still other cases a posterior eth- 
moid cell is prolonged into the wing of the sphenoid. The relations 
of these sinuses are described as follows. Above a mere shell of 
bone separates them from the optic nerve and chiasm and the brain 
itself. The nasal fossa and the anterior part of the great sphenoidal 
sinus form their floor. In front lie the posterior ethmoidal cells, 
while along the outer wall runs the optic nerve, and if the sinus is 
of large size the carotid artery and the Vidian nerve are found 
in close proximity. The wall of the orbit may be formed in part 
by that of the sinus. Obviously distention of the sinus by pus or 
absorption of its contents creates disturbance in contiguous structures 
while the risk of damage to the latter in operating is a serious 
possibility. The existence of this anomaly thus adds not a little to 
the difficulty of diagnosis and the complications of operative inter- 
ference. Yet it is claimed that in some cases it may be easier to 
enter the sphenoidal sinus by cutting away the posterior ethmoidal 
cells and through the smaller wing than by the route usually followed 
in the vicinity of its normal opening. 

The plan of gaining access to the sphenoidal by way of the max- 
illary sinus was first suggested by Jansen. He especially advises it 
in those cases of sinusitis with cerebral complication, in which a 
rapid and thorough operation must be done, also in cases in which 
an antral empyema coexists, as well as in those in which the maxil- 
lary sinus is not involved, but the nasal route cannot be followed 
owing to atresia or deformity of the nasal fossae. The proportion 
of cases in which the sphenoid cannot be reached through the nasal 



90 DISEASES OF THE NOSE, THROAT AND EAR. 

passages, if necessary after a preliminary removal of obstructions 
must be extremely small. 

The particular method of opening the sinus is less important than 
that the aperture should be ample and as near as possible to the floor 
of the cavity. Spiess prefers to puncture the anterior wall by means 
of a trephine propelled by electricity. Hajek tears down the anterior 
wall with a hook passed through the sphenoidal orifice, while 
Grunwald, after having enlarged the opening with a sharp spoon, 
breaks off portions of the bony wall in a downward direction with 
his punch forceps. If on exposure of the cavity it seems to be nec- 
essary to curette its walls the greatest caution should be observed 
in the region of its roof, where the thin plate of bone might easily 
be penetrated with most disastrous results. Free drainage, removal 
of all diseased tissue, followed by swabbing the cavity with pure 
carbolic acid and occasional antiseptic irrigations subsequently are 
said to bring most of these cases to a successful termination in the 
course of a few weeks. The risk of hemorrhage in opening the 
sphenoid is much increased by the proximity of the cavernous sinus 
and of the internal maxillary artery. From the latter a branch 
passing through the sphenopalatine foramen sends a small twig 
across the anterior face of the sphenoid to supply the mucous mem- 
brane of the nasal septum. In a case reported by Hinkel a very 
severe hemorrhage occurring on the tenth day is believed to have 
had its source in the sphenopalatine artery. Several similar cases 
of bleeding, primary as well as secondary, are on record in which 
the flow was arrested by the use of a firm tampon. The difficulty 
of diagnosis and the danger of surgical interference are thus seen 
to be much greater in the case of the sphenoidal than of the other 
accessory sinuses. 

HYDROPS ANTRI. MUCOCELE AND CYST. POLYPI. 
FOREIGN BODIES AND NEOPLASMS. 

The ancient term hydrops antri is deemed inconsistent with 
modern ideas of pathology. It seems to be quite certain that a 
serous or muco-serous effusion may take place into a sinus cavity in 
the congestive stage of an inflammatory process which never ad- 
vances to suppuration. For such a condition the term mucocele is 
appropriate. In a very remarkable case recorded by H. Luc the 



17 i 



CYST OF THE MAXILLARY SINUS. 9 1 

frontal and maxillary sinuses of the same side were affected by 
mucocele without discoverable cause, the disease being cured by the 
usual operation performed for empyema of these cavities. He 
refers to a similar case reported by Laurens in which the ducts from 
the affected sinuses were occluded by an enormous osteoma. It is 
not improbable that a mucoid collection may occur in a sinus more 
often than is generally supposed, since a non-inflammatory process 
of this kind is attended by so few subjective symptoms. It is 
possible that an escape of fluid into the antrum may occur in the 
course of a general dropsy. But these cases are extremely rare. 
An accumulation of non-purulent fluid in a sinus cavity is in many 
cases properly called a cyst, the walls of the sinus forming its bound- 
aries, in consequence of disappearance of its original limiting 
membrane by distention, rupture and absorption. In cases of long 
standing this is likely to be the course of events, whether the process 
has its inception in a lymph space or in the acinus or duct of a gland, 
or begins as a dentary cyst. Hence an actual cyst wall is seldom 
seen. It is suspected that some cases of alleged nasal hydrorrhea 
are of this kind. The antrum of Highmore is the most frequent seat 
of this phenomenon. When the ostium maxillare becomes blocked 
from any cause and the secretion causes distention, more or less pain 
or swelling may call attention to its existence. In time the anterior 
wall of the sinus becomes so thin that characteristic crepitation on 
palpation may be detected. In the case referred to in discussing the 
diagnosis of empyema of the antrum the contrary was true and it 
was supposed that we had to deal with a solid tumor, until its 
character was demonstrated by the light test. The quality of the 
effusion is usually such as to offer no obstacle to transillumination. 
In a case detailed by Fergusson exploratory puncture showed the 
nature of a tumor previously supposed to be solid, while Heath 
refers to a case within his own knowledge in which the upper jaw 
was removed before the error in diagnosis was discovered. The 
quantity of fluid varies from a drachm or two to several ounces. It 
is colorless or faintly straw colored and may be clear or slightly 
turbid. Cholesterin is usually found in abundance. Occasionally 
the fluid is quite dark or even greenish and in a case recorded by 
Maisonneuve it presented a buttery consistency. The researches 
of W. Adams, followed by Giraldes, seem to show that cysts begin- 
ning in the glandular follicles of the mucous membrane may be 



92 DISEASE S Or THE NOSE. THROAT AND EAR. 

single or multiple and may easily escape detection in the ordinary 
way of tapping the antrum. In general mere evacuation of the 
fluid effects a cure. If the cysts are very numerous it may be nec- 
essary to curette the wall of the antrum and afterward use astringent 
irrigations. It is wise to open the cavity freely in order that bony 
septa or foreign bodies may not be overlooked. The inconvenience 
to the patient resulting from such a course is insignificant, while its 
advantage over simple aspiration must be apparent. 

Polypi may develop in the lining membrane of a sinus and un- 
dergo cystic degeneration precisely as they sometimes do in the 
nasal chambers. Or their presence may excite a profuse watery 
secretion which escapes by way of the nasal fossae and is mistaken 
for a nasal hydrorrhea. Spencer Watson quotes an interesting case 
of this kind observed by Paget in which the actual condition was 
demonstrated by post-mortem inspection. Until symptoms due to 
pressure or distention appear it may be impossible to offer a diag- 
nosis. Watson calls attention to certain extra or dinar}- cases of cyst 
of the antrum associated with optic neuritis and nerve atrophy. I: 
would seem that some of the cases included by him in this cate- 
gory, in which symptoms of cerebral disturbance were exhibited, 
might to-day be regarded as instances of escape of cerebrospinal 
fluid, a condition to be referred to in the chapter on nasal neuroses. 
Intranasal polyps often coexist and it is by no means unreasonable 
to suppose that a condition favoring the development of the former 
may extend to the mucous membrane lining the accessor}- sinuses. 
This especially applies to the ethmoid cells, which are almost invari- 
ably found in a state of polypoid degeneration in inveterate cases of 
nasal polyp. Xasal suppuration is not proportionate to the degree 
of sinus disease. It has several times been my experience to open an 
antrum or a frontal sinus and find extensive degeneration of its 
mucous lining with scanty pus accumulation. The discharge is 
sometimes slightly offensive, a fact perceptible to the patient if his 
sense of smell is preserved. Heath declares that polypi of the 
antrum are very vascular, a fact undoubtedly true of malignant 
disease but less admissible regarding simple gelatinous polypi. In 
fact excessive hemorrhage from a tumor connected with the nasal 
passages must always be looked upon as a danger signal. Simple 
mucous polypi are not very vascular and spontaneous hemorrhage 
is unusual. A polyp attached within the antrum has been known 



FOREIGN BODIES IN A SINUS. 93 

to protrude into the adjacent nasal fossa, but as a rule sinus polypi 
are small and multiple. The proper treatment for a case of this 
kind is to thoroughly open the sinus and curette every part of the 
affected mucous membrane. 

Foreign bodies are occasionally found in a sinus, especially the 
maxillary. Missiles from firearms, teeth erupted in the wrong 
direction or driven into the cavity in attempts at extraction, lost 
drainage tubes used in treating a sinus empyema are among the 
most common. In certain countries animal parasites are not in- 
frequently discovered in these cavities, where they often cause 
extreme disturbance and sometimes extensive destruction of tissue. 
A diagnosis is difficult unless the larvae are found in the nasal dis- 
charges. A foreign body may be retained a long time without 
giving any positive indication of its presence. In a case reported 
by Lohnberg a piece of metal was exposed in the ethmoid cells 
after removal of a large number of nasal polyps. Twenty years 
before this patient had lost an eye by explosion of a gun and 
unquestionably the piece of metal had at that time penetrated the 
orbital wall and become lodged in the ethmoid region. In a second 
case the patient was hit on the forehead with a wrench, a fragment 
of felt being torn from his hat and driven into the frontal sinus. It 
excited a chronic suppuration for which an operation was under- 
taken and the foreign body was thus discovered. Heath refers to a 
case in which a knife blade was lodged in the antrum for forty-two 
years and was finally expelled from the nostril, and describes 
another remarkable case in which a gun breech found its way into 
the throat after having remained twenty-one years in the antrum. 

Neoplasms, either benign or malignant, are met with in a sinus, 
having originated there or having invaded it from adjacent parts. 
The latter is far more frequent, at least as regards malignant disease. 
In this situation a benign tumor, although less accessible, is operable 
as elsewhere, but the question of a malignant tendency or perhaps a 
mixed character, especially at certain periods of life, has always to be 
answered. Malignant disease involving the antrum and more 
rarely the other accessory sinuses has generally been regarded as a 
desperate condition. It may assume the type of sarcoma or epithe- 
lioma and is so insidious and rapid in its development that in most 
cases it is beyond reach by the time its character is made known. 
The age and condition of these patients generally preclude extensive 



94 DISEASES OF THE NOSE, THROAT AND EAR. 

surgical operations, so that many surgeons prefer to attempt de- 
struction of the growth by the actual cautery and escharotics. 
Malignancy here is no exception to the law applicable to it elsewhere, 
namely, that it is curable by the knife, provided all of the disease and 
every infected lymph channel and gland be extirpated. The 
difficulty is to define accurately the limits of disease. So-called 
recurrence means a failure to accomplish this end at the original 
operation. Those who realize what it is to face the agonies of slow 
death from an eroding cancer may prefer to take the chances of 
surgery even though most unpromising. 

In a series of cases of malignant disease of the nose and accessory 
sinuses collected by J. S. Gibb are found five of carcinoma and three 
of sarcoma primary in the antrum or other sinuses. In three of the 
former death from recurrence took place (Dombrowski, Bolan-2) 
of one, in which an excision of the upper jaw was done, no subse- 
quent history is given (Bolan), and in the fifth, in which the antrum 
was curetted through the alveolus, there had been no return after 
fourteen months (W. C. Phillips). Of the cases of sarcoma two had 
recurrence and died (R. Levy, S. M. Burnett) and one, a case of 
osteosarcoma, in which the upper jaw, the turbinates, the palate, 
the vomer and parts of the ethmoid and malar bone were removed, 
had no recurrence eight years later. No doubt many cases have not 
been put on record. In this connection a remarkable case of suc- 
cess with Coley's toxin treatment in a spindle-cell sarcoma of the 
upper jaw is of interest. An attempt had been made to remove the 
tumor by an excision of the upper jaw, but failed and the growth 
rapidly increased in size. A few injections of the toxins of erysipe- 
las and the bacillus prodigiosus were made in the tumor and afterward 
all were made in the abdominal wall. Although the actual condition 
of the affected parts is not stated, Coley declares that " the patient 
practically recovered and resumed his occupation." As an evidence 
of improved nutrition an increase of thirty pounds in weight while 
under treatment is noted. Some skepticism might be permitted as 
to the diagnosis in this case, but for the fact that the verdict rests 
not only on the clinical symptoms but also on microscopical exami- 
nation by an expert. While much of the testimony regarding the 
toxins is negative or distinctly unfavorable, their use is certainly 
justifiable in cases of recurrent sarcoma or in those decided to be 
inoperable. 



MALIGNANT DISEASE OF A SINUS. 95 

From a study of this subject by Schwenn suppuration, fetor, 
rapid extension and recurrence would seem to be the main character- 
istics of malignant disease of a sinus. Pain also is almost invariably 
present and may be intermittent and neuralgic from compression of 
a nerve trunk or continuous from distention of the walls of the 
affected cavity. The tendency of malignant disease of the antrum 
to perforate at several points on the cheek or into the orbit is observed. 
Perforation may occur in simple empyema but only at one situation 
and only in case drainage is absolutely cut off. Ocular symptoms 
are prominent when the anterior ethmoid cells are involved. It is 
difficult to determine whether displacement of the eyeball,' dis- 
turbance of the lachrymal apparatus, or other eye symptoms are due 
to trouble originating within the orbit or in the ethmoid cells, 
especially when there is no nasal obstruction and no visible tumor 
in the nasal fossa. In most cases there is more or less obstruction of 
one nostril and in nearly every case the septum is attacked. Nasal 
breathing may not be much impeded. On the contrary when the 
disease springs from the posterior ethmoid cells the growth projects 
into the nasopharynx and obstructs the passages. In the latter case 
also the orbit is almost always invaded with involvement first of the 
sixth and then of the optic nerve and corresponding ocular disturb- 
ance. Tumors of the sphenoidal sinus cause a great variety of symp- 
toms, impairment of hearing, of vision, of smell, of taste, trigeminal 
neuralgia, ill-defined headaches and finally cerebral symptoms. 
Their growth is usually very rapid, and the success of radical inter- 
ference is extremely remote. 



CHAPTER V. 

DISEASES AND DEFORMITIES OF THE NASAL SEPTUM. DEVIATION. 

ECCHONDROSIS. EXOSTOSIS. ULCERATION. PERFORATION. 

HEMATOMA. ABSCESS. CONGENITAL OCCLUSION OF THE 

NARIS. ADHESIONS. COLLAPSE OF THE NOSTRIL. 

DISLOCATION OF THE COLUMNAR CARTILAGE. 

FRACTURE OF THE NOSE. 

DEVIATIONS OF THE SEPTUM. 

The etiology of deviated septum has been the subject of much 
controversy. It is met with very early in life and has been pro- 
nounced congenital in certain cases. It is doubtful whether syphilis 
is a factor in its causation, but many cases exhibit more or less 
evidence of scrofulous taint. In a certain proportion of cases we 
succeed in getting a history of traumatism and, when we consider 
how exposed the nose is to external injury and how much of the 
time is spent upon this organ in babyhood, we realize that the con- 
dition may be induced by frequent repetitions of mild degrees of 
violence, as well as by a single severe injury. 

The attempt has been made to classify deviations of the septum 
in accordance with the forms they assume, but the variations are so 
unlimited that a strict classification is not feasible and is clinically 
valueless. 

In general we speak of horizontal, vertical and sigmoid devia- 
tions. In the first the long axis of the deformity is antero-pos- 
terior, in the second it is at or near a right angle to the floor of the 
nose, and in the last the septum is seen to bulge into one nostril 
above and to the opposite side at its lower part, thus assuming a 
sigmoid or S form. In some cases the bowing of the cartilage is 
gradual and symmetrical, in others there is a narrow deep furrow 
on one side and a corresponding sharp prominence on the other, as 
if the septum in its plastic state had been compressed in its vertical 
plane, or, as Lennox Browne puts it, "a crumpled partition" exists. 
The first is by far the most frequent form and the second the rarest. 

9 6 



DEVIATIONS OF THE NASAL SEPTUM. 97 

Sigmoid deviations are quite common and are perhaps the most dif- 
ficult to deal with. One of the most intractable deformities of the 
septum is that in which an anterior deflection of the cartilage is asso- 
ciated with a displacement of the bony septum into the opposite 
naris, constituting what may be called a horizontal sigmoid devia- 
tion. Opinions differ as to whether excessive height of the palatal 
arch almost always seen in connection with a deviated septum bears 
a relation of cause or effect. The concurrence of adenoids with 
septal deflection and a high narrow hard palate, especially in young 
subjects who are mouth-breathers, is a matter of common observa- 
tion. It is probable that the same diathetic state is concerned in 
the etiology of each of these conditions. The fact that deviations 
of the septum are seldom seen in early life, with a history of injury, 
would enforce the theory that most of these cases are due to arrest 
of palatal development or overgrowth of septal tissue, or both 
combined. In early fetal life the hard palate is above the level 
of the Eustachian tubes and gradually descends in process of normal 
development. The Gothic arched palate must be looked upon as a 
frequent result of the maldevelopment often associated with adenoids 
in the rhinopharynx and consequently as one of the causes of septal 
deformity. Mayo Collier contends that deflections occur at the 
thinnest and weakest part of the septum, in consequence of relatively 
increased atmospheric pressure due to rarefaction of air on inspira- 
tion, which latter results from some form of obstruction in the nostril. 
This certainly cannot be regarded as a satisfactory explanation of 
all varieties of deviation. 

In the majority of cases the cartilaginous septum is chiefly af- 
fected; no matter how great a bending may exist in the anterior part 
we find the posterior margin of the vomer maintaining a vertical 
position. Hence there is always a sacrifice of breathing space, the 
wider nostril admitting no more air than its narrowest portion allows 
to pass. The simplest form of deviation is that consisting of a bow- 
ing of the cartilage, one side being concave, the other convex, with- 
out marked thickening. Associated with the deflection more or less 
enlargement of the inferior turbinate body opposite the concavity of 
the septum exists as a result of nature's effort to prevent the admis- 
sion of an undue volume of air. The hypertrophy, therefore, is a 
result, not a cause, of the deviation, though the latter may appear 
to be the case at first glance. 



QO DISEASES OF THE NOSE, THROAT AND EAR. 

The frequency of deviation is remarkable; an absolutely straight 
septum is almost unknown. Inspection of a very large number of 
skulls in various museums has shown that distortion of the bony 
septum is present in much more than half of the cases examined. It 
is reasonable to infer that deformities of the cartilage are far more 
frequent. Associated with the deviation, in a large proportion of 
cases, there is more or less thickening of the septum, especially at 
the apex of the bend in the form of ecchondrosis, or hyperchondro- 
sis, and over the vomer, exostosis. A thickening is also particularly 
observable along the junction of the quadrilateral cartilage with the 
vomer and the perpendicular plate of the ethmoid. Its preponder- 
ance along sutural lines gives credibility to the traumatic theory of 
causation, an arthritis being excited by a blow or fall which results 
in piling up of tissue along the lines of articulation. In other cases, 
however, where there is an absence of thickening, which would seem 
to be of inflammatory origin, the impression is given that the bending 
is a result of overgrowth, or hypernutrition, the development of 
the septum continuing after the bones of the face have undergone 
consolidation, so that there is insufficient rcjm in the vertical line 
for its accommodation. 

The symptoms induced by a deviated septum are those referable 
chiefly to nasal stenosis. In cases of extreme displacement, there 
may be some deformity of the external nose, the tip being tilted or 
twisted from the median line. Not infrequently the symmetry of 
the nostrils is impaired, or the columna nasi may be displaced. The 
effects of nasal stenosis are displayed, to a considerable degree, in 
the region immediately behind an obstruction and in the lower air 
tract as well. In no small proportion of cases laryngeal symptoms 
are distinctly traceable to a deviated septum, and a condition of 
congestion in the postnasal space may involve the Eustachian tubes 
and lead to a train of annoying ear symptoms. Behind the stenosed 
area, the air being rarefied with each inspiration, a condition of 
chronic congestion is induced in the mucous membrane which eventu- 
ally leads to hypernutrition and hyperplasia. In case of complete 
stenosis, the functions of the nostril are entirely abolished. The 
impediment to inspiration is still further aggravated by collapse of 
the nostril on the affected side in consequence of the increased 
rapidity of the entering current of air, or weakness of the alar mus- 
cles. The effect upon the voice of stenosis due to septal deviation 



DEVIATIONS OF THE NASAL SEPTUM. 99 

is often very marked; the quality and tone are impaired both from 
the abolition of the resonating chamber and from the associated 
catarrhal condition; in consequence, increased phonatory effort is 
likely to result in voice strain. In addition, we may have developed 
a train of reflex nerve symptoms, to be elsewhere considered, when 
the deviation is so exaggerated as to cause pressure upon a turbinate 
body. 

The diagnosis of deviation is not difficult if one takes pains to 
compare the nostrils and to explore the nasal fossae by means of a 
probe, with the finger tip, or, if need be, with a septometer. (See 
Fig. 10.) 

The prognosis under the present method of managing these cases 
is good so far as the lesion itself is concerned. As regards compli- 
cating disorders the outlook will depend in great measure upon the 
duration of the condition. In nearly every case we shall succeed in 
giving a certain amount of amelioration, if not complete cure, which 
will be permanent provided corrective measures are not undertaken 
too early in life. 

The only treatment for the condition is surgical. The earliest 
attempts to correct the deformity consisted in pressure upon the dis- 
placed cartilage by means of the finger repeated by the patient him- 
self at short intervals (Quelmalz, 1750). Various plastic operations 
have been recommended in which the mucous membrane is dissected 
up and redundant portions of the deflected cartilage excised, the soft 
parts being subsequently replaced or brought together by means of 
sutures (Heylen, 1845). More elaborate operations consist in 
raising the tip of the nose by external incision or by the incision of 
Rouge, so as to allow free admission to the nasal cavities. Among 
the early operative resources, for a long time popular, was that known 
as the method of Blandin, which consisted in the removal of one or 
more segments of cartilage by means of a punch, no effort being made 
to save the mucous membrane. This resulted in permanent perfora- 
tion of the septum. For many years what is known as Adams' 
operation was practised, in which the septum was seized with forceps 
and fractured in. such a way as to permit its replacement in the 
middle line (Fig. 47). The broken septum was retained in proper 
position by ivory plugs which were worn until firm union. The 
results of this operation have been disappointing for various reasons. 
In the first place, the shape of the deformity varies so much in differ- 



100 



DISEASES OF THE NOSE, THROAT AND EAR. 



ent cases that no one method is applicable to all. Thickening at 
the apex or convexity of the deformity is often more important than 
the deflection itself, and, finally, the deformity tends to recur, since 
the spring of the cartilage is not fully overcome. In not a few 
instances simple removal of the overgrowth of tissue on the convex 
side restores the air current sufficiently so that any attack upon the 




Fig. 47. — Adams' Septal Forceps. 

septum beyond this is found to be unnecessary. In many cases 
removal of the thickened portion with a saw answers every purpose 
(Bosworth). In others where the thickening does not constitute 
an abrupt spur or ridge, the drill, or nasal trephine of Holbrook 
Curtis (Fig. 48) is found to give better satisfaction. The trephine 
is passed at several levels or the projecting shoulders left above 
and below its track are smoothed off with rongeur forceps. The 



4 




Fig. 48. — Nasal Drills, Trephines and Burrs. 

drill and trephine are most conveniently operated by the electro- 
motor, and the saw also may be used with electric power. It is 
necessary to reduce a swollen turbinate before attempting to replace 
a bent septum. All these minor, or preliminary operations are 
done under cocaine anesthesia. But few would be able to endure the 
pain involved in fracturing and readjusting the bony septum with- 



DEVIATIONS OF THE NASAL SEPTUM. IOI 

out a general anesthetic. For cases of simple deflection without 
thickening the pin operation of Roberts gives good results. In 
this operation an incision is made along the prominence of the 
deflection with a bistoury, the parts are then pushed over into 
position, the edges of the cut overlapping each other, where they 
are held by means of a long steel pin passed through the columna 
from the concave side across the line of incision and into the septal 
tissues above and behind. The head of the pin protrudes from the 
nostril, or may be concealed in the vestibule, and does not interfere 
with the breathing; it should remain in place a week or longer until 
the replaced septal fragments have become consolidated. More 
than one pin may be required to give proper support, a second 
being passed directly backward through the dorsum of the nose. 
It is important that the cartilage should be thoroughly loosened in 




Fig. 49. — Steele's Septum Punch. 

order to obviate undue pressure from the shaft of the pin; other- 
wise there is danger of its cutting its way through the tissues. An 
obvious advantage of this method, where applicable, is that nasal 
breathing is not interfered with. Attempts to remedy the defor- 
mity by multiple incisions, or by stellate incisions with a forceps 
like that devised by Steele (Fig. 49) and modified by Sajous and 
others, have been only moderately successful. Roe prefers to break 
the septum without lacerating the soft parts, and for this purpose 
uses a special forceps, one blade of which is larger than the other 
and fenestrated (Fig. 50). The blades are made of different sizes 
and are adjustable to a common handle. In Roe's operation the 
solid or male blade is inserted in the convex side and the ring blade in 
the opposite nostril. The solid blade fits the ring loosely, and when 
the instrument is closed other portions of the septum than that 
immediately compressed are not disturbed. The importance of 
fracturing the bony septum in most cases is insisted upon, and it is 
claimed that it may be done with this instrument without any of the 
risks incident to the twisting and rocking motions necessary with 



102 DISEASES OF THE NOSE, THROAT AND EAR. 

other septal forceps. In many cases the comminution of the septum 
accomplished by Roe's forceps does not wholly overcome the redun- 
dancy of the tissue which must be provided for by preliminary inci- 
sions of the cartilage. These incisions should be made oblique, or 
beveled, so as to permit the fragments to override each other. Thus 
the thick ridges formed when the septum has been straightened after 
cuts at a right angle to its vertical plane are in part avoided. If the 
cartilage is not excessively redundant these incisions are made 
from the concave side only to the perichondrium of the convex side, 
the finger in the latter nostril readily guiding the knife. Usually 
two incisions, a horizontal and a vertical one, crossing at the point 
of greatest deformity are required, and a special cartilage knife with 
a shield which may be used to limit the depth of the cut is recom- 
mended. Turbinate hypertrophies, adhesions and so far as possible 




Fig. 50. — Roe's Septum Forceps. 

ridges and spurs of the septum should be removed before attempts 
at straightening are undertaken. A ridge projecting from the inter- 
maxillary bone in the floor of the nose often present in these cases 
may be broken with the forceps, but not infrequently a saw or 
chisel is needed if the bone is very dense. For holding the septum 
in right position a metal plate wound with cotton or gauze to the 
proper size is preferred to any other mechanical appliance as well 
as to the tubes in common use. It is left in a place for three or 
four days, then removed, the parts cleansed with warm borated 
bichloride solution, 1 to 5,000, and a fresh plug inserted for two days, 
by which time the septum is usually firm in its corrected position. 
A tendency to recurrence of deformity may be arrested by the 
introduction of a non-perforated hard rubber or aluminum tube for 
a few days. The preliminary work is done with cocaine and su- 
prarenal extract; the actual fracturing under primary chloroform 
anesthesia. 

A mode of operating suggested by E. J. Moure presents several 
interesting features and is claimed by its promoter to have certain 



DEVIATIONS OF THE NASAL SEPTUM. 



IO3 



advantages. Three stages are outlined as applicable to the majority 
of cases, although the three conditions to be met are not always 
found. In the first place a ridge of cartilage, or ecchondrosis, 
at the apex of the deviation is removed with an elliptical ring 
osteotome (Fig. 51). In the second place the antero-inferior border 
of the cartilage, which is often luxated into the nostril opposite the 
convexity of the deviation, is shaved off with a bistoury, after having 
been button-holed by an incision along its most prominent part. 
Finally after these wounds have healed, that is, in the course of a 
month, the deviation, itself is attacked. The direction of the in- 
cisions and the intranasal splint used for supporting the septal frag- 




Fig. 51. — Moure's Osteotome. 



ments differ from those in other operations. The cuts are made 
with scissors, almost identical with those of Asch, the first one nearly 
parallel with the floor of the nose and as close as possible to the 
inferior attachment of the cartilage (Fig. 52). A second cut is made 
obliquely upward and as close as possible to the dorsum of the nose. 
leaving a somewhat narrow bridge of cartilage between the anterior 
ends and a very wide one between the posterior ends of the incisions. 
This triangular movable fragment of cartilage is held in front at the 
tip of the nose by a band of cartilage and behind by the perpendicu- 
lar plate of the ethmoid and the vomer. A special tube, composed 
of two parallel blades, the outer one rigid to rest upon the turbinate 
the inner one malleable, is then introduced. The malleable blade 



io4 



DISEASES OF THE NOSE, THROAT AND EAR. 



is then molded against the deviated cartilage, thus correcting the 
deflection to the desired degree, by means of dilating forceps passed 
into the tube (Fig. 53). The tubes, which are made in pairs, one 
for either nostril, are left in situ for at least eight days, a single tube 
being used only on the convex side in a given case. This method of 




Incisions in Moure's Operation. 



operating is said to be rapid and not attended by much hemorrhage. 
Local anesthesia with cocaine is all sufficient, pain, if any, being 
due to the tube rather than the operation itself. No local treatment 
is advised, unless there is a good deal of purulent secretion, in which 
case the nasal fossae may be douched twice a day with warm boracic 
acid solution, and the same is applied externally for the relief of 





Fig. 53. — Moure's Nasal Tube and Dilating Forceps. 

pain. Uniformly good results are claimed for this method of 
operating at least in adults. It is considered unwise to touch the 
septum until development is complete, that is, not before the 
sixteenth year. 

In the operation described by Braden Kyle a V-shaped wedge of 
muco-chondrial tissue is resected antero-posteriorly, the base of the 



DEVIATIONS OF THE NASAL SEPTUM. 



IO: 



wedge^looking toward the convexity and its apex toward the con- 
cavity* of the deviation. It may be necessary to remove several of 
these V-shaped pieces in order to overcome redundancy, especially 
one on the concave side near the floor of the nose, and even the bony 
septum may be included (Fig. 54). The so-called " V-shaped 
sawfile" devised by Fetterolf is preferred for making the excisions 
(Fig. 55). If the incisions are made at the proper places and in 




Fig. 54. — Kyle's Operation for Deflected Septum by Removal of V-shaped Segments. 
a and b show the location of incisions and the position assumed bv the septum after 
the removal of the wedge-shaped pieces. The uppermost of these incisions seems to 
be on the wrong side of the septum in the diagram and in actual practice it is found 
impossible to make it along the line indicated. 



sufficient number there will be no need of great violence in breaking 
up resiliency. Malleable metal tubes are preferred for supporting 
the replaced septum, and may be left in situ many weeks without 
risk, since they may be perfectly fitted to the position they occupy. 
There is no danger of perforation provided the blood supply is not 
interfered with by making the incisions too close together in parallel 
lines. It is important also to preserve intact the mucous membrane 
of the septum on the side opposite the cuts. 



V". 



Io6 DISEASES OP THE NOSE, THROAT AND EAR. 

^ A Tare variety of septal deformity consists of a 

displacement of the whole mass of the partition 
so that its lower border rests on the floor of one 
or the other nostril. There is little or no curva- 
tion or redundancy. Invariably there is more or 
less bending of the anterior nasal spine toward 
the narrow nostril combined with hyperostosis, 
so that the vestibular floor is converted into a 
mere fissure. Such a deformity is supposed to 
be an immediate result of violent traumatism, 
the associated hyperplasia of bone and cartilage 
being a natural consequence of the subsequent 
reparative process. For the condition described 
the supralabial operation of Harrison Allen seems 
to be admirably adapted. Strange to say, it is 
f very little known, but its merits have recently 
£ been forcibly urged by A. A. Bliss, from whose 
description the following is condensed. The 
frenum of the upper lip is first divided with a 
small sharp-pointed bistoury. A chisel with a 
cutting edge one-fourth to three-eighths of an 
inch in width is passed into the wound upward 
to the base of the maxillary crest and then driven 
with a few blows of the mallet directly backward 
through the nasal spine as far as the nasopalatine 
foramen. At once it will be found possible to 
push the septum over with the finger as far as 
may be desired,, provided the section has been 
complete. Unless the premaxilla is unusually 
high, so that the floor of the vestibule is on a 
higher plane than the floor of the naris in general, 
the mucous membrane will not be perforated by 
the chisel. In any case the accident is not of 
much consequence. The septum is held in its 

' 1=5 corrected position by means of a rubber tube 

I pp* splint, cold-water dressings are applied externally. 

^ and the nares are sprayed even* two hours with 

an alkaline antiseptic solution. The operation is done under light 
etherization, and roughnesses mav be smoothed down at once or 



DEVIATIONS OF THE NASAL SEPTUM. IO7 

later under cocaine. The simplicity of this procedure, its effective- 
ness and the absence of marked reaction commend it in this peculiar 
form of septal deviation. The patient is kept in bed a day or two 
and the tube is dispensed with after the second week, making the 
duration of treatment about the same as in other operations. 

The fact has been mentioned that one of the earliest methods 
resorted to for relieving the subjective symptoms caused by a 
deviated septum was the formation of a perforation by punching out 
more or less of the deformed cartilage. Later attempts were made 
to save the mucous membrane by dissecting it from the cartilage and 
resecting as much of the latter as might seem desirable. Among the 
first to do this operation was Ingals, who removes a triangular seg- 
ment of cartilage from the anterior face of a convex deviation, then 
detaches the posterior remnant of cartilage from the floor of the nose, 
forces it into the median line and holds it in position by a tampon 
of lint charged with iodoform and boric acid. The cartilaginous 
triangle removed has its apex above and its base below, and its 
dimensions vary with the degree of deformity. The bony ridge 
jutting from the floor of the nose which supports the septum is re- 
moved with saw, chisel, or trephine. In cutting the cartilage Sajous' 
knife is used and care is taken not to damage the mucous membrane 
covering the concavity. If the depression is abrupt or angular it is 
difficult to avoid perforating, but the flap of mucous membrane 
formed on the convexity will cover such a lesion. The direction 
and extent of the primary incision through the mucous membrane 
must vary with the shape of the deformity. The soft parts are 
separated from the cartilage by means of a specially designed spud 
and should be elevated over a considerable area in order to save 
them from being torn. Shurly quotes Escat as practising a submu- 
cous injection of water so as to lift off the membrane covering the 
concavity and thus protect it from injury while the cartilage is 
being incised. Anteriorly the soft tissues are quite adherent and 
must be dissected up, while posteriorly it is easy to raise them with 
a suitable elevator. 

The " window-resection" operation of Krieg (Fig. 56), or what is 
generally known as "submucous resection," aims to remove the 
deformed cartilage and bone from between the layers of mucous 
membrane, a flap being formed on the convex side. In the early 
experiences there seems to have been some hesitation in attacking 



io8 

the bone. Nowadays its removal is considered quite as important 
as that of the cartilage. Difficulty experienced in stripping up the 
mucous membrane led to the practice of leaving it intact only on the 
concave side (Boenninghaus). If a wide area is included the in- 
evitable result is incrustation of secretion at the site of operation 
which often continues indefinitely. Valuable suggestions have been 
made by many others, especially Killian, whose name is often 
attached to the operation. Relying upon the assumption that the 
nasal septum is merely a partition and gives no support to the 




a 
Fig. 56. — Krieg's Operation for Angular Deflection of Septum. 

external nose, Otto Freer independently planned an operation 
differing from that of Krieg in only a few details (Fig. 57). For- 
merly he was in the habit of fracturing the bone with Roe's com- 
minuting forceps, after having fissured the bone with chisel or 
trephine. At present he prefers a powerful modification of Griin- 
wald's cutting forceps and removes bone as well as cartilage, in the 
opinion of some to an extreme degree, yet he claims never to have 
met with any deformity of the external nose as a result and the 
muco-perichondrial septum is invariably sufficiently firm. In 
order to gain more space in the operative field he strongly urges mak- 
ing a "reversed L-incision" through the mucous membrane, an 
anterior triangular flap being formed with its base toward the tip of 
the nose. At the conclusion of the operation no intranasal splints 
are needed, but the nostrils are packed with strips of lint loaded 
with powdered bismuth subnitrate. This dressing is said to remain 
aseptic for at least ten days. The objects of the tampon are to 
prevent secondary hemorrhage and to hold the flaps in place. The 



DEVIATIONS OF THE NASAL SEPTUM. 



IO9 




Freer's Instruments for Submucous Resection. 



V2, hoes; V, dull for lifting edge of cartilage after incision; Y2, sharp, for cut- 
ting out pieces of denuded cartilage; A, knife, bent on edge, for denudation from 
right naris of left side of bony ridge on nasal floor; E, knife for splitting periosteum 
over bony ridge and for dissection; I, round-bladed knife, bent on the flat, for dissect- 
ing reversed L flap from below; H, Ingals' cartilage knife; M, broad-bladed elevators. 
sharp and blunt; N, chisel; O, periosteal raspatory, keen-edged, for denuding the 
ridge and vomer (new); X, short slender elevators, sharp and blunt; Y, long eleva- 
tors for use in the deeper regions; D, knife for incision outlining the L flap i^also small 
size for children and narrow nostrils)' T, Freer-Grunwald reinforced bone forceps: 
R, S, retractors for nostrils; Q, long retractor for mucous membrane flaps, (Courtesy 
of Dr. Freer.) 



no 



DISEASES OF THE NOSE, THROAT AND EAR. 



operation is done under local anesthesia with cocaine crystals, which 
are claimed to give most complete insensibility to pain with a mini- 
mum of toxic effects. Moderate chloroform anesthesia must be 
used in children. In addition adrenalin provides a bloodless opera- 
tive field. It is said that in some cases new cartilage and bone are 
regenerated from the preserved perichondrium and periosteum. 
Experience with the method up to the present time shows that this is 
not essential, a firm partition is formed and the mucous membrane 
in course of time resumes its function and becomes moist and free 
from incrustation. 





Fig. 58. — "Window-Resection" Operation for Curved Deflection to Right 
Lower Border of Septal Cartilage Projecting in Left Naris. (Krieg.) 



with 



The enthusiasm with which submucous resection of the deviated 
septum was greeted has rarely been equalled. It was generally 
adopted by rhinologists, most of whom have something to offer in the 
line of instruments or operative technic. While it is true that the 
procedure is simplified by the use of certain instruments, it is not 
desirable to multiply them excessively. It is not a simple opera- 
tion, but rather demands unusual fortitude of the patient and ex- 
ceptional skill and patience from the operator. The objection 
urged against it that it sacrifices physiological structures is un- 
tenable since it cannot be reasonably contended that a strongly 
deviated septum causing atresia of the nostril and its familiar train 
of subjective symptoms is performing a normal function. On the 
contrary, it should be treated like any other diseased structure and 
remedied by the method which experience proves to give the best 
functional results. Many who have had very large opportunity for 



DEVIATIONS OF THE NASAL SEPTUM. Ill 

observation firmly maintain that it meets the indications in every 
form of deviation. It is undeniably a somewhat tedious procedure, 
but with increased experience the time of the operation will be 
shortened and the discomfort of the patient proportionately reduced. 
In exceptional cases it may be completed in twenty minutes; in some 
when the mucoperichondrium shows adhesions which must be care- 
fully dissected several hours are consumed. Usually the field is 
well exposed by a single vertical or slightly oblique incision in front 
of the deviation, extending from above to the floor of the nose 
(Killian). It should be carried through the perichondrium on the 
convex side. The soft parts are then elevated from above down- 
ward with sharp or blunt elevators as may be required, risk of tearing 
the flap being less with the former when carefully used. This is 




Fig. 59. — -Ballenger's Sub-mucous Knife. 

done more easily as one proceeds backward, but great care should be 
taken to get beneath the perichondrium and to avoid perforation of 
the flap in approaching the angle of the deviation. In extreme 
deflections it is well not to attempt to go beyond this point until a 
later stage, or after the anterior part of the cartilage has been taken 
out of the way. 

The next step is division of the cartilage along the line of the 
primary incision. For this purpose a sharp curette, or preferably 
the septum knife of Freer or Killian, is used. With an elevator 
passed through this cut the mucoperichondrium is stripped from 
the concavity. The cartilage now lies exposed in a sack of mucous 
membrane and is to be removed in mass with a Ballenger swivel 
knife (Fig. 59) or piecemeal with a cutting forceps. Obstacles to 
the former are found in thick and sharply angular septa; with bone 
the latter only is available. The bone composing the maxillary 
crest must next be carefully denuded, if concerned in the deformity 
as it usually is. It is sometimes so dense that a powerful forceps is 






112 DISEASES OF THE NOSE, THROAT AND EAR. 

needed for its excision (Fig. 60). All distorted cartilage and bone 
having been removed, it only remains to support the flaps with plugs 
of sterilized gauze. A tube in one nostril permits nasal breathing and 
is less uncomfortable. No stitches are required, and after twenty-four 
hours the tampons may be dispensed with. They keep the mucous 
surfaces in contact and prevent effusion of blood between them, 
an occasional annoying accident. A hematoma thus formed may 
go on to suppuration, when it must be treated as an abscess of the 
septum, and it sometimes results in perforation. A laceration occur- 
ring in the course of the operation is usually covered by the intact 
membrane of the opposite side. A perforation of moderate dimen- 
sions is not of great moment. It is wise to leave a wide strip of 
cartilage anteriorly to support the external nose and obviate a possible 




Fig. 60. — Carter's Septum Forceps. 

danger of retraction. The suspicion arises that its occurrence 
in the rare instances reported may be explained by the existence in 
the patient of some constitutional taint. Under such conditions no 
operative interference should be considered. Almost every writer 
on this topic gives a minute description of his own particular method 
which he regards as by far the best, but after all a great deal depends 
upon the ingenuity and skill of the individual operator. The prepa- 
ration and position of the patient, the mode of inducing anesthe- 
sia, the special instrument adapted to a given situation and the 
dressing of the wound are all open questions to be decided largely 
by personal preference and experience. The results attained by 
submucous resection are in the majority of cases almost ideal. 
Yet it should not be resorted to in children during the formative 
period of life, in the aged, or in those without the capacity to endure 
a somewhat long and trying operation. 

In hardly any other field is the fact so conspicuous that the per- 
fection of an operative procedure is due not to a single individual 
but to contributions from many sources. Although these operations 



DEVIATIONS OF THE NASAL SEPTUM. 



XI 3 



on the nasal septum carry personal titles, which for convenience they 
are likely to retain, yet in no instance can it be said that they are 
the exclusive creation of those whose names they bear. Thus the 







Fig. 6i. — Asch's Instruments for Deviated Septum Operation. 
a, Compressing forceps; b, angular scissors; c, straight scissors; d, sharp separator; 
e, blunt separator. 

Asch operation is really an adaptation of various new and useful 
technical details to a principle which has long been recognized. 

This operation must be done under general anesthesia and 
with the head of the patient dependent in what is known as 
Rose's position. Thus the risk of blood or coagula being drawn 
8 



114 DISEASES OF THE NOSE, THROAT AND EAR. 

into the larynx is abolished (Fig. 61). The special instruments 
required are first a pair of scissors, after the pattern of a "but- 
ton-hole" scissors, that portion of the shank between the cut- 
ting edge and the joint being curved outward to avoid compress- 
ing the columna when the instrument is closed. Second, a curved 
gouge for breaking up adhesions. Third, a septal forceps, of the 
Adams' or similar design. Fourth, an intranasal splint to hold the 
parts in position until repair is complete. Various shapes and mate- 
rials have been experimented with, tin, cork, Bernays' sponge, soft 
rubber and hard rubber. A hollow tube, made of the last mentioned 
material, flattened laterally and with its anterior end larger and 
shaped to fit the vestibule of the naris gives satisfaction. Some 
of these vulcanite nasal tubes have numerous perforations into 
which the mucous membrane is supposed to protrude and thus pre- 
vent the tube from slipping. . By many a smooth tube is preferred, 
and if one of correct size has been selected and the spring of the 
cartilage has been destroyed it will stay in place. It permits nasal 
breathing and drainage and can be easily kept clean with the least 
possible disturbance of the wound. Before the operation the nostrils 
should be thoroughly irrigated with an antiseptic solution. The next 
step is to introduce a finger into the stenosed naris in order to learn 
the precise shape of the deformity and whether adhesions are pres- 
ent. The latter may be broken down with the finger or with the 
gouge. One blade of the scissors, which is blunt and dull, is passed 
into the contracted nostril, the other, which is sharp, into the wide 
nostril, and the cartilage is divided through its whole thickness at its 
point of greatest deviation on a line nearly parallel with the floor of 
the nose. A second cut is then made across the middle of the for- 
mer and as nearly as possible at a right angle to it. Thus the carti- 
lage is divided into four triangular segments nearly uniform in size. 
These segments are then broken at their bases by twisting them 
vigorously with the septal forceps. As a matter of fact they are not 
actually broken but are merely released from their bony attachments. 
This step of the operation demands the exercise of force, since success 
depends upon its thoroughness. A supporting tube should be 
selected as large as the nostril will admit and retain without excessive 
pressure, a matter which it is well to determine beforehand. It is 
best to proceed deliberately and control the bleeding if possible 
between the stages of the operation. In rare cases the tube and even 



DEVIATIONS OF THE NASAL SEPTUM. 



US 



a tampon must be inserted before the hemorrhage can be checked. 
The patient should be kept quiet for a day or two and the parts 
gently irrigated with a warm boric acid solution every twelve hours 
without moving the tube. The occurrence of much pain, marked 
swelling of the external parts, or decided elevation of temperature 



&O0000 





Fig. 62. — Nasal Tubes, a, Asch's hard rubber; b, Kyle's malleable; c, cork. 

are indications for withdrawal of the tube and possible substitution 
of a smaller size. The secret of success in this, as in all operations 
for deviation, lies in destroying the resiliency of the cartilage. The 
intranasal tube should be worn at least for two weeks and. in extreme 
cases, even longer and should be large enough to till the nostril 



Il6 DISEASES OF THE NOSE, THROAT AND EAR. 

without producing painful pressure (Fig. 62). It should be left 
undisturbed for three or four days, the nostril being cleansed 
through it by means of douches or coarse spray of alkaline solution. 
The tube may be easily removed after thoroughly washing the nos- 
tril with an alkaline solution and spraying with albolene, and its 
replacement is painless under cocaine. Unless some special 
indication arises it is desirable to avoid handling the parts more 
than is absolutely necessary to keep them clean. 

The bleeding during these operations for deviation of the septum 
is frequently considerable but is usually arrested by the pressure of 
the tube with the addition of a plug on the opposite side if necessary. 
As a rule, a tube is placed only in the convex side. An accident 
which sometimes happens is annoying but not a source of great 
discomfort, namely, the occurrence of necrosis along the line of 
incision. My personal preference for making the division of the 
cartilage is a sharp-pointed curved bistoury which can be more 
precisely controlled than the scissors, the incisions being made along 
the lines of greatest deviation and exactly to the desired extent. 
A septum knife, devised especially for this purpose, is thought by 
some to be more convenient. One of the best methods of checking 
bleeding when not excessive is the introduction of pledgets of 
absorbent cotton soaked in hot water, or adrenal extract. 

As a preliminary it is customary to cleanse the nasal fossae 
thoroughly with a normal salt or a saturated boric acid solution. 
Immediately after the operation the parts frequently look unpromis- 
ing in consequence of thickening of the cartilage from overlapping 
fragments. Not infrequently we find projecting from the floor 
of the nose a spur or ridge from the intermaxillary bone which may 
finally require removal by means of a saw, chisel, or trephine. 
Nevertheless, it is well not to be in too much of a hurry to attack 
these thickenings and irregularities since it is remarkable to what 
extent their absorption is accomplished. 

It is very obvious that repair is retarded and the patient is sub- 
jected to needless discomfort by too much meddling with the parts 
after operation. It is impossible to keep these wounds absolutely 
aseptic and the effort to do so by assiduous cleansing with powerful 
antiseptics is to say the least unwise. While evidence of the bac- 
tericidal power of nasal mucus is not conclusive this fluid does not 
appear to be a good medium for germ growth, and it is certainly a 



DEVIATIONS OF THE NASAL SEPTUM. 117 

clinical fact that wounds of the intranasal structures do uniformly 
well, provided they are not subjected to extraordinary irritation or 
the original violence was not excessive. As a rule, gentle cleansing 
once in twenty-four hours with a simple detergent solution, Seller's 
or DobelFs, will be enough to prevent accumulation and decomposi- 
tion of secretion and will give nature a fair chance. 

An excellent method of treating certain forms of simple deviation 
of the cartilaginous septum without thickening was suggested at 
about the same time by Watson and Gleason, of Philadelphia, their 
methods differing only in certain unimportant details. The opera- 
tion of the latter consists of forming a U-shaped flap of the whole 
thickness of the cartilage by inserting a saw at the lower limit of the 
deflection and sawing first obliquely and then directly upward as 
far as necessary to include all of the deformity, the arms of the U 
being extended, if need be, by means of a blunt bistoury; in the case 
of the anterior arm the bistoury is passed on the convex side, and of 
the posterior arm on the concave side, of the septum. In this way 
the lines of incision may be prolonged to any desired extent. The 
flap should be made large enough to completely include the de- 
formity, and is forcibly pushed over to the concave side so as to 
destroy the spring at its attachment above as completely as possible. 
Thus the pendulous U is retained by the margins of the incision. 
The chief advantage of this mode of overcoming the deformity is 
that there is seldom necessity of intranasal support. The disadvan- 
tage is that a considerable amount of irregularity is necessarily left 
and it occasionally happens that slight perforations may exist at 
some part of the wound. With this, as with other modes of oper- 
ating, it is well to postpone measures for correcting irregularities 
for a considerable time in order to allow the parts to mold them- 
selves. 

In Watson's method a similar incision is made upward at the 
crest of the deviation without going through the mucous membrane 
on the concave side. The muco-cartilaginous flap thus formed is 
forced over to the wider nostril, where it is held by its beveled edges. 
This provides for a horizontal deviation. If a vertical deflection 
coexists a wedge-shaped piece of the cartilage, large enough to dis- 
pose of the redundancy, is excised. 

These operations may be done under cocaine. General anesthesia 
is indispensable when the forceps is to be used in fracturing the 



Il8 DISEASES OF THE NOSE, THROAT AND EAR. 

osseous septum. Great care should be exercised in handling the 
bony septum, especially its upper portion. The magnitude of septal 
operations must not be underestimated, and the general condition 
of the patient should be considered. In certain physical states the 
loss of blood and the shock to the nerve centers from the intranasal 
traumatism are elements of grave danger. Interference should 
by all means be postponed until the conditions, local and systemic, 
are restored to a desirable standard. There is reason to believe 
that the disasters which have been chronicled as sequels of these 
operations, but by no means peculiar to them, such as hemorrhage, 
suppurative sinusitis and even sepsis, are referable to neglect 
of careful scrutiny of the patient's condition. It is often a difficult 
matter to decide what is the best operation in a given case. In 
a large majority the Asch operation will give a satisfactory result, 
at least when the bony septum is exempt from deformity. Owing to 
the warnings given by Emil Mayer and by Asch himself, attempts to 
fracture the bone with the forceps are regarded as dangerous. In a 
case reported by Robert Levy fatal sepsis occurred and Freer refers 
to a case in which suppuration of the sphenoidal sinus followed the 
operation. Such accidents as these, and fracture of the turbinates, 
as in the experience of Stucky, would seem to be fairly explained 
by some error in technic or some obscure morbid state in the indi- 
vidual operated upon. The violence required even to fracture the 
bony septum is in no degree comparable with that inflicted in many 
traumatisms with no untoward results beyond merely local damage. 
Hemorrhage in the Asch operation with the head dependent is nat- 
urally more free than when the patient is erect, but has been some- 
what reduced since it became the custom to use a thorough prelim- 
inary application of adrenalin. The objection offered to the Asch 
tube that it is too much curved is overcome in part by Mayer's 
modification and completely by that suggested by McKernon, in 
which the lower border of the tube is straight, and in addition the 
last has its upper anterior border rounded so as to fit into the hollow 
of the nasal vestibule without producing irritation. Moreover, it 
has the advantage of not being perforated. Most of the tubes in 
common use are too small at their distal end to give enough support 
to a deflection extending far back in the naris. All tubes made 
of hard rubber or other inflexible material are unsatisfactory 
for the reason that they cannot be molded to the nostril. The 



DEVIATIONS OF THE NASAL SEPTUM. 119 

latter objection is obviated in the malleable tubes used by Kyle 
and others. The cork splint of Berens and the compressed cotton 
tampon (Bernays' sponge) of Simpson, either of which may be 
readily shaped to suit the case, deserve further trial. The former is 
cut as desired at the time of operation and is made aseptic by being 
coated with iodoform collodion. A thin plate of vulcanite has been 
added by Chappell to the septal surface of the latter, which makes 
the splint firmer and prevents adhesion of the cotton fibers. If the 
cotton swells excessively it is a simple matter with a broad-bladed 
forceps to extract a layer or two from the middle of the splint. 
A plan proposed by J. G. Roberts is to fasten plates of sheet par- 
affin, or dental wax, to the surfaces of the Simpson splint by means 
of aristol-collodion. Thus the splint is introduced and withdrawn 
with equal ease and while in place the soft paraffin molds itself 
in a measure to the surfaces with which it is in contact. 

One of the most annoying complications of a deflected septum is 
a disfigurement of the external nose caused by an abrupt bend at the 
junction of the cartilage with the nasal bones. It is most common 
in traumatic cases and frequently one or the other nasal bone is de- 
pressed. It is impossible to correct the deformity until the bone has 
been restored to its normal place. This may sometimes be done 
with a Sinexon's nasal dilator, or with a powerful forceps, like that 
devised by Walsham, one blade of which is to be applied within and 
the other outside the nostril. In some cases there is a good deal of 
thickening at the prominence of the angle, a result of the original 
injury, which may be shaved down by a guarded electric burr in- 
troduced through the nostril, the skin having been first dissected 
from the hard parts. Or it may be more comfortably removed by 
external incision, provided the patient is willing to wear the trifling 
scar that may follow such a wound. In most cases cosmetic effects 
are considered less important than restoration of breathing space, 
yet by the exercise of a little care and ingenuity much may be done 
to remedy these unsightly distortions. 

The relation of a V-shaped or Gothic arch of the palate to 
deflections of the septum, the subject of instructive study by Dean. 
Mosher and others, is of great importance. Correction of the oral 
deformity, especially early in life, by widening the dental arch de- 
presses the floor of the nose, expands the nasal cavities and gives 
space for restitution of a bent septum without sacrifice of tissue. 



120 DISEASES OF THE NOSE, THROAT AND EAR. 

ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 

Ridges or spurs of the nasal septum may consist of cartilage or of 
bone. In the former case they are called ecchondroses, in the latter 
exostoses. They may exist quite independently of deflection of the 
septum. Exostoses are met with generally far back in the region of 
the vomer, although it is not unusual to see indications of ossification 
in anterior ecchondroses of long standing, especially those near the 
floor of the nose, or a septal ridge may consist of cartilage in front and 
behind of bone. The possible admixture of osseous tissue has an 
important bearing on the selection of a mode of correcting these 




Fig. 63. — Ecchondrosis of Septum Embedded in Right Inferior Turbinate, with Deep 
Groove on Opposite Side. (Krieg.) 

deformities. A pure ecchondrosis, situated well forward, may be 
readily removed with a bistoury. A long antero-posterior ridge 
should be attacked with a saw, since bony tissue offers too great 
resistance to a knife blade. 

The varieties of shape assumed by these deformities are almost 
without limit. Usually they are very irregular; rarely they are 
symmetrical. Most frequently, perhaps, their lower surface is more 
or less horizontal, while above they shade off gradually into the 
septum (Fig. 63 and 64). 

The diagnosis of an ecchondrosis is free from difficulty if both 
nostrils be carefully inspected. A septal protuberance is seen in one 
nostril without proportionate depression of the opposite side of the 
septum. The tumor is hard, insensitive, and covered by mucous 
membrane unaltered or tense and thin. At the apex of the spur the 



ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 



121 



membrane may be eroded. Exostosis of the septum is less easily 
detected, frequently being concealed by an anterior turbinate en- 
largement or a deviation of the cartilage. The use of cocaine and 
the nasal probe may be essential to its discovery. A septal exostosis 
rarely impedes breathing, but it is believed to be a prominent factor 
in many obstinate derangements in the postnasal region and in the 
lower air track. It must offer more or less obstruction to nasal 
drainage and be a source of irritation by impinging upon or becom- 
ing adherent to a turbinate body. It is often pyramidal or almost 
conical in shape. It occurs only in adults, a fact which, taken in 
conjunction with its situation on a part of the septum supposed to be 




Fig. 64. — Bilateral Ecchondrosis of Septum. (Krieg.) 



protected from injury, excludes a traumatic theory of etiology. In 
fact, it seems impossible to explain the origin of these singular 
deformities. 

By far the best instrument for removing these overgrowths is the 
nasal saw. The ring-knife or " spoke-shave " is much inferior 
especially in dealing with dense bone. A long thin-bladed saw with 
teeth set and cutting from behind forward has given me the most 
satisfaction. It makes very little difference whether the handle be 
straight or angular, as one may readily become accustomed to either 
(Fig. 65). It is well to make a preliminary cut through the mucous 
membrane from below upward in order to obviate the danger of 
stripping up the soft parts. The excision of the mass itself is most 
conveniently made from above downward. The saw should be 
applied at an angle until the soft parts are cut through, when it may 



122 



DISEASES OF THE NOSE, THROAT AND EAR. 



be brought to a vertical position and the section completed, the 
object being to prevent slipping of the instrument and consequent 
incomplete removal of the redundant tissue. Under cocaine and 
adrenal extract the operation is painless and almost bloodless. In ex- 
ceptional cases each of these agents may fail to produce its legitimate 
effect, owing usually to individual idiosyncrasy. In the opinion of 
many, secondary hemorrhages have been more frequent and serious 
since their introduction, and firm plugging of the nostril is therefore 




Fig. 65. — Bosworth's Nasal Saws. 



advised by some in all these cases. My own feeling is strongly averse 
to the routine use of the intranasal plug, and my experience has been 
to be called upon to apply it quite as frequently before the cocaine- 
suprarenal era as since the use of these drugs became general. 
Fifteen or twenty minutes after the conclusion of the operation, when 
all oozing has ceased, both nostrils should be sprayed freely w r ith the 
suprarenal solution, followed by mentholized albolene. The patient 
should be cautioned to keep quiet, avoiding physical exercise and 
mental excitement for the succeeding twenty-four hours, and the 



ECCHONDROSIS AND EXOSTOSIS OF THE SEPTUM. 1 23 

necessity of a nasal plug will seldom arise. The after-treatment is 
limited to keeping the parts clean and to preventing the formation of 
adhesion. The latter is accomplished by gently passing a probe 
between the opposed surfaces or a hard-rubber nasal bougie may be 
introduced every second or third day. In a spacious nostril and a 
tractable patient it is an advantage to save the membrane by a sub- 
mucous operation as for deviation. 

The treatment of septal spurs by electrolysis has many advocates. 
There are two methods of applying it, one called the unipolar and 
the other the bipolar system. The latter is more generally practised. 
The source of electricity is a thirty-cell galvanic battery, or pref- 
erably the Edison current, of no volts, modified by a suitable con- 
troller. A strength of from fifteen to forty milliamperes is re- 
quired. The needles are of steel, or gold-plated, in an adjustable 
handle. The former material is recommended by Moure and 
others, but a steel needle at the positive pole oxidizes and must be 
renewed at each sitting. Iridoplatinum needles are free from this 
objection and being indestructible may be fixed in a permanent 
handle (W. E. Casselberry). The pain of the operation is very 
slight under cocaine, and there seems to be no doubt that cartilagi- 
nous spurs may be dissipated by this method. The energy and 
duration of the current should not be excessive for fear of perforation 
of the septum, an accident which is avoided by suspending the ap- 
plication the moment a mottling of the mucous membrane of the 
opposite side appears. The action of electrolysis is sorbefacient, 
that of the electric cautery is destructive. Yet in reading the 
histories of reported cases of so-called electrolysis one cannot escape 
the suspicion that many of them belong in the latter category. We 
read of a slough separating at the end of a week followed by a granu- 
lating surface with pronounced loss of substance. Surely this is not 
electrolysis! Many authorities vigorously denounce the use of the 
galvano-cautery on the septum. My own experience convinces me 
of its safety and efficiency in ecchondroses of moderate dimensions. 
Much of the prejudice against it is founded upon its improper use in 
unsuitable cases. Electrical methods at best are inferior to cutting 
and are permissible only in timorous patients or in those to whom 
a loss of blood might be detrimental. Any method involving a wide 
sacrifice of mucous membrane is objectionable. In extensive de- 
formities flap or plastic operations are preferred. 



124 DISEASES OF THE NOSE, THROAT AND EAR. 

ULCERATION OF THE SEPTUM. PERFORATION. 
HEMATOMA. ABSCESS. 

Ulcers of the septum may occur as a result of mechanical irritation 
due to special occupations or maybe symptomatic conditions attended 
by local vascular changes. The apex of a deflection is a common 
site of ulceration owing to the lodgment of secretion which the 
patient removes with his ringer. This is noticed particularly in 
young people, an abrasion of the septum following a wound due to 
the habit of picking the nose. Ulcerative processes may also follow 
acute fevers, typhoid, or specific disease. In the last the process 
usually begins in the perichondrium or the periosteum and involves 
the mucous membrane secondarily. In syphilis the bone as well as 
the cartilage is apt to be affected. This is true of almost no other 
ulceration occurring in the nose. The situation of the ulcer 
depends in part upon its cause, but most ulcers are seen about the 
middle of the cartilaginous septum. 

Overtreatment may result from the anxiety of the patient to 
obtain relief. In most cases simple cleanliness followed by the ap- 
plication of mild astringents is all that is necessary. Exuberant 
granulations may need to be removed by cauterization or curetting. 
The formation of scabs should be prevented by the application of an 
ointment of vaselin containing ten grains to the ounce of boric acid, 
or a mixture of white precipitate ointment and oxide of zinc oint- 
ment in the proportion of one of the former and three of the latter. 
The last mentioned is particularly useful in specific ulcerations and, 
of course, in the latter condition we are called upon to adopt at the 
same time a vigorous constitutional treatment. A probable result 
of ulceration, especially when it is extensive and deep, is perforation 
of the cartilage, an accident which may not be of serious import, but, 
on the other hand, may be followed by some inconvenience as well as 
disfigurement. A perforation situated well forward and having 
thick edges is affirmed by Myles to cause the greatest annoyance. A 
theory of etiology held by C. W. Richardson and others is that the 
destructive process results from lowered vitality and resisting power 
of the cartilage due to defective innervation. Tuberculous disease is 
discovered in a considerable proportion of cases of perforation. Its 
occurrence in workers in mercury, arsenic and other chemicals has 
long been known, and Toeplitz reports having discovered it in a 
large number of those employed in an establishment for the manu- 



PERFORATION OF THE SEPTUM. 125 

facture of Paris green. When the perforation involves only the 
cartilage it is usually of simple origin, although the ravages of 
syphilis may be, in rare cases, limited to the cartilaginous septum. 
Often the perforation is traced to an injury which results in the 
formation of a hematoma. In the majority of cases a hematoma 
undergoes resolution without destruction of tissue; in others sup- 
puration takes place and the tissues break down unless an early 
outlet is given to the pus. An abscess of the septum, if allowed to 
pursue its own course, almost invariably results in perforation with 
more or less sinking in of the dorsum of the nose. It is a curious 
fact that a perforation of considerable size may exist without the 
knowledge of the patient. It has been my experience to see almost 
complete loss of the cartilaginous septum after typhoid fever without 
external deformity or inconvenience. The rapidity of the process 
and the resulting deformity vary in different cases. At a meeting 
of the Laryngological Society of London, W. G. Spencer related the 
case of a boy in whom a hematoma just within the nares followed a 
fall on the face. There was no suppuration or immediate deformity, 
but two years later the bridge of the nose began to sink and the nasal 
septum became much thickened and twisted, probably in conse- 
quence of chondritis and softening resulting from the injury. There 
was no history of syphilis. On the other hand, Haviland Hall 
referred to the case of a woman of sixty in whom a septal abscess 
destroyed the cartilage and caused marked deformity within three or 
four weeks. It seems to be the general belief that in young people 
during the period of development these occurrences produce more 
deformity than in adults. Perforations are very apt to give more 
trouble when their long diameter is vertical than when it is horizontal. 
Frequently a whistling noise is noticed in respiration and there is a 
tendency to incrustation of secretion at the margins of the opening. 
It occasionally happens that a perforation results from necrosis 
along the line of incision after the operation for deviated septum. 

The disturbance caused by a perforation of the septum is generally 
so trifling that active interference is not called for, unless the patient 
is annoyed by blood-stained secretions or by a whistling sound in 
breathing. Healing of the margins of a perforation is often retarded 
by retraction of the mucous membrane, the cartilage thus being ex- 
posed. Reflection of the membrane and resection of the protruding 
cartilage so as to permit union of the apposed mucous surfaces has 



126 DISEASES OF THE NOSE, THROAT AND EAR. 

been advocated (Goldstein). Several ingenious plans have been 
proposed for covering the aperture. In one flaps are formed by 
making curved incisions in front of and behind the perforation on 
opposite sides of the septum. These bands are raised from the 
cartilage and slid over the perforation, one being sutured to its 
posterior and the other to its anterior margin. Thus areas of de- 
nuded cartilage appear on opposite sides of the septum in front and 
behind, while the opening is covered by the mucous flaps (Burton 
Haseltine). By still another method a flap is dissected from the 
inferior turbinate from which it is completely detached after it has 
become firmly united to the margins of the perforation (Chevalier 
Jackson) . 

It is important that we should recognize the existence of abscess 
promptly in order to evacuate the pus early by free incision. If 
the collection of pus is extensive it may be necessary to incise upon 
both sides, but usually a single incision is sufficient. The important 
point is to make the cut near the floor of the nose and wide enough 
to give good drainage. It is well to keep the edges of the cut apart 
by a bit of iodoform gauze until the suppurative process begins to 
abate. At first the pus cavity should be thoroughly washed out with 
peroxid of hydrogen or boric acid solution and the nostrils should be 
cleansed with an alkaline spray or douche. There is seldom any 
difficulty in diagnosing an abscess. The tumor which it forms is 
generally bilateral and symmetrical and is distinctly fluctuating to 
the finger or the probe. 

CONGENITAL OCCLUSION OF THE NARES. 

Closely allied to the subjects just considered is that of stenosis of 
the nares by bony occlusion of congenital nature. Many cases of par- 
tial or complete obstruction due to a web of soft tissue or adventitious 
membrane are on record, but those in which the obstacle is bony 
are very rare. Of the latter, in nearly every case the condition has 
been observed in the posterior nasal region. The impediment may 
consist of an exostosis from almost any part of the bony framework 
of the nasal fossa or of a plate of bone growing from the floor or 
outer wall of the cavity. Unless both choanae are involved the sub- 
jective symptoms may be insignificant. Under the latter circum- 
stances a nursing infant might suffer from the effects of malnutri- 



CONGENITAL OCCLUSION OF THE NARES. 1 27 

tion. On the other hand, a single patulous nostril may carry enough 
air to conceal the condition until the child reaches an age to observe 
that but one nostril is doing its duty. 

In a case of my own, a girl of eighteen, no discomfort was caused by the 
anomaly, except slight impairment of hearing on the corresponding side. In 
this case the obstruction was complete and consisted of an outgrowth from the 
hard palate. The septum was deflected toward the stenosed side and the 
turbinate structures in that fossa were almost rudimentary. The sense of smell 
was less acute than normal. With the electro-trephine a button of bone one- 
quarter of an inch thick at its lower and one-eighth at its upper margin was re- 
moved, evidently from a plate springing from the floor of the nose. The 
immediate result was restoration of the nasal air tract and after a few weeks 
manifest improvement in the sense of smell. No impression was made on the 
hearing and the patient was annoyed as she had not been previously by accumu- 
lation of secretion in the affected nostril. In a case of this kind, therefore, the 
wisdom of interference is doubtful. 

The state of things is very different, however, in acquired stenosis 
from a developing exostosis or in a condition of double atresia. Here 
the subjective disturbance may be very distressing, or intervention 
may be imperative for preservation of life. In order to determine 
the character of an obstruction, whether bony or membranous, it is 
necessary to explore with the finger in the posterior naris and with 
a sharp probe from the front. A soft obstruction may be penetrated 
and destroyed with the galvano-cautery, one of bone must be attacked 
with the drill or trephine. The tendency to closure by granulation 
tissue and adhesions is very marked, and in many cases it has been 
found necessary to use nasal tubes and dilators for a long period in 
order to preserve the patency of the nostril. 

Membranous occlusion may exist at almost any part of the nasal 
passage as a congenital malformation, or as a result of struma or 
syphilis. It may be relieved by multiple incisions, or, if very thick, 
by excision of redundant tissue and the subsequent use of a nasal 
tube so long as a tendency to contraction persists. Partial atresia of 
the choana has been found by W. G. Porter in one out of three 
persons examined. A membranous fold from the septum, the roof 
of the nose, or the middle turbinate, or perhaps involving all three 
situations, is thought to be a vestigial remnant of the bucco-nasal 
membrane. It is usually situated 10 or 15 mm. in front of the choana 
and sometimes includes a thin plate of bone. It has no clinical 
importance unless unusually extensive. 



128 DISEASES OF THE NOSE, THROAT AND EAR. 

INTRANASAL ADHESIONS. 

An accident likely to occur after cauterization of the turbinate body 
or after an operation upon the septum, especially in a narrow nostril, 
is an adhesion or synechia between the walls of the nasal fossa. Price 
Brown justly lays great stress upon the fact that in many cases this 
results from neglect of after-treatment, the absence of pain and dis- 
comfort leading the patient to underestimate the importance of 
attention. A similar condition may result from erosions or ulcera- 
tions occurring spontaneously and is frequently seen in the strumous. 
The adhesions may consist of bone, of cartilage, or of fibrous tissue. 
It most frequently exists between the middle turbinate and the 
septum, or the turbinates themselves may unite. An ulcerative 
process may be instituted by a foreign body or by pressure resulting 
from a hyperplastic rhinitis. Adhesions obstruct breathing more 
or less according to their situation and are frequent causes of a 
variety of reflex disturbances. In many cases a chronic catarrhal 
naso-pharyngitis or a persistent tinnitus aurium may be the only 
prominent symptom. When the adhesion is composed of fibrous 
tissue it may be divided with scissors or with the galvano-cautery 
knife; when composed of bone or cartilage the redundant tissue 
must be removed with a saw or drill. In the after-treatment the 
case should be watched with great care in order to prevent recurrence ; 
and, with this object in view, it is important that a considerable 
bridge of tissue should be removed. If care in this respect be 
observed the use of plugs and tampons will be quite unnecessary. 
On the contrary some consider it safer to insert a tampon of rubber 
tissue or even absorbent cotton soaked in albolene, which it is 
claimed may be left in many days without discomfort or danger, 
in the meantime the passage being cleansed daily with antiseptic 
sprays. In the course of convalescence it may be necessary to 
touch exuberant granulations with some astringent solution, chromic 
acid, zinc, or nitrate of silver. Until complete repair is accomplished 
the patient is not absolutely secure against reformation of the 
synechia. 

COLLAPSE OF THE NOSTRIL. 

In consequence of weakness of the muscular apparatus controlling 
the nostrils or a maladjustment of the lateral cartilages some indi- 



DISLOCATION OF THE COLUMNAR CARTILAGE. 1 29 

viduals suffer more or less inconvenience from collapse of the alee, 
nasi especially during forced respiration and in sleep. The condition 
is frequently aggravated by thickening or by distortion of the col- 
umna nasi or by an ecchondrosis of the septum. In the latter case 
the trouble is restricted to one nostril and chiefly impedes inspira- 
tion. The difficulty may be overcome by directing the patient to 
wear a tube which supports the nostril and reaches just within the 
vestibule or the so-called nasal dilator, consisting of a pair of pads 
connnected by a U-spring, one pad intended for either nostril. The 
pad or dilator is worn only at night or for a limited period during the 
day. At the same time -it is claimed that good results are obtained 
from massage and from electrization of the alar muscles. A septal 
deformity must be corrected. W. J. Walsham succeeded in support- 
ing a collapsed nostril by the following ingenious operation. A flap 
of mucous membrane with its base uppermost was dissected from 
the inner wall of the nasal vestibule. The surface of the depression 
where the lower lateral cartilage bends was then made raw. The 
epithelium covering the flap, the width of which was about three- 
sixteenths of an inch, was then scraped off, the flap rolled upon itself 
like a bandage and secured in the depression at the border of the 
cartilage by a stitch of fine fishing-gut passed through the septum 
into the opposite nostril and back again. The little ball of tissue 
prevented the ala from caving in during inspiration and the cure 
of the condition is said to have been permanent. Harke, who has 
given a good deal of attention to this subject, notes the frequent fail- 
ure of removal of a posterior obstruction to restore nasal breathing 
owing to paresis or possible atrophy of the muscles which should 
dilate the nostril. He favors mechanical support for the weakened 
structures, and it would seem entirely reasonable to expect results 
from measures intended to improve muscular tone in other situations, 

DISLOCATION OF THE COLUMNAR CARTILAGE. 

There is no separate columnar cartilage, the name being applied to 
the reflected portions of the lower lateral cartilages which assist in 
forming the partition between the nostrils. Obstruction of one or 
the other nasal vestibule may be caused by distortion of this cartilage 
or by displacement of the lower border of the cartilage of the sep- 
tum. The entrance of the naris, or limen vcstibuli. may be cod- 
9 



130 DISEASES OF THE NOSE, THROAT AND EAR. 

verted into a narrow longitudinal slit, the outer limit of which is a 
prominent fold on the inner surface of the ala especially described 
by Roughton. When collapse of the nostril is added to these anom- 
alies of the cartilage the affected side becomes almost useless espe- 
cially on inspiration. Attempts have been made to remedy the 
difficulty by divulsion and by section of Roughton's band without 
success. The wearing of rubber tubing in the nostril, or the use of 
nasal expanders, or any form of dilatation is merely palliative. 
These measures give a certain amount of comfort to those who are 
averse to operative interference. If the columnar cartilage is at 
fault a V-shaped incision through the mucous membrane permits 
the cartilage to be exposed and the excess shaved off with a blunt 
bistoury or scissors. The triangular cartilage is readily reached 
by a plastic operation or the projecting portion may be cut off 
en masse without regard to saving the mucous membrane. If 
the area of the latter thus sacrificed is not too extensive the soft tis- 
sues are regenerated and the membrane recovers its function. 
Otherwise more or less scar surface results over which incrustations 
of secretion may give some annoyance. The best remedy for this is 
the application of unguents containing ichthyol or carbolic acid. 
Cocaine should be applied freely and may be injected into the mem- 
brane in case it is necessary to cut near the muco-cutaneous junction. 
No dressing is needed except a pledget of sterilized cotton or gauze 
to hold the flaps in place after a plastic operation. 

FRACTURE OF THE NOSE. 

What is called a broken nose is usually a luxation of the septal 
cartilage. The degree of violence required actually to fracture the 
nasal bones or the intranasal framework is generally so extreme as 
to induce grave symptoms of cerebral damage. The precise location 
and extent of the local lesion may be obscured by swelling, unless 
the case is seen very soon after receipt of the injury, and the diagno- 
sis and treatment may call for the exercise of the utmost skill and 
patience. If the nasal bones are simply depressed it is an easy mat- 
ter to replace them by means of an elevator passed into*the nostril 
and retain them in place with pledgets of iodoform or nosophen 
gauze. If they are impacted it is often very difficult to raise them, 
and if the case is complicated by comminution and displacement 



FRACTURE OF THE NOSE. 131 

of the septum and perhaps by fracture of the maxilla the problem con- 
fronting us is much more serious. In the latter case some form 
of extranasal apparatus is required as well as an intranasal sup- 
port. Restitution of displaced parts having first been effected, the 
nostrils are plugged with iodoform gauze, or a rubber hood, or 
finger-stall is inserted and stuffed with the desired quantity of 
sterilized cotton. Either of these will check hemorrhage and give 
adequate support, but the latter is more readily removed. Both of 
these are objectionable because they compel mouth breathing, and to 
avoid the discomfort of that condition a hollow tube of rubber, vul- 
canite, or malleable material, like that used after an operation for 
deviated septum, may be introduced and around it cotton or gauze 
is packed as needed. For an external splint layers of gauze 
impregnated with plaster of Paris, which are moistened and then 
molded properly and allowed to set, are found satisfactory. A 
splint made of sheet zinc and lined with felt extending from the tip 
of the nose to the forehead is recommended by W. H. Daly. This 
is molded to the nose and held in place by five tails, two at its lower 
edge which pass around the head under the ears, two from its upper 
edge across the forehead and above the ears, and a fifth which 
passes backward over the vertex from its upper margin. The 
five ends are fastened together at the back of the head. F. C. 
Cobb advises a firm head-band of steel, to which are attached 
pads capable of being adjusted to any part of the nose and the 
pressure of which may be regulated according to necessity. It is 
prevented from slipping by bands going across the head and under 
the chin. A rather ingenious splint has been devised by Jesse 
Hawes for a bad case of fracture in which he was annoyed by an 
upward tilting of the tip of the nose. It consists of a piece of No. 15 
spring brass wire bent in the form of a rectangular letter U, long 
enough to extend from the middle of the upper lip over the top of the 
head. The arms of the U are intended to rest on either side of the 
nose, its lower portion being slightly bent outward so as to avoid 
pressure on the upper lip. Each arm is bent sharply forward at an 
angle opposite the supraorbital ridge and a second time in such a 
way as to carry it backward over the top of the head. The angles of 
the wire well padded are pressed firmly under the supraorbital ridge 
where they are held by a broad band of adhesive plaster, completely 
encircling the head above the eyes. The tip of the nose is then 



132 

drawn down by means of silk ligatures passed through the septum 
and the mucous membrane and cartilage of the alae and fastened to 
the transverse part of the splint. Depressed portions of the nose 
are supported by means of intranasal springs of wire covered 
with rubber tubing and attached to the horizontal arm of the splint. 
The elastic property of rubber is utilized in an external support 
of tubing, especially when lateral displacements exist. Many sur- 
geons discard splints of all kinds, relying wholly upon the natural 
support given by the arch of the nasal bones. Perfect results 
are secured provided readjustment of the parts to a normal posi- 
tion has been accurate. In exceptional cases following extraordinary 
violence or when a tendency to recurrence of deformity is displayed 
some form of splint is required. Under ordinary circumstances 
with an Adams' or Asch's septum forceps and by manipulation 
of the external nose with the fingers a fracture may be reduced 
with cocaine anesthesia. In children and in complicated cases 
general anesthesia is a decided advantage. J. Wright reminds us of 
many curious and some valuable expedients familiar to the ancients, 
who were evidently acquainted with the objection, which most of us 
share in modern times, to the prolonged retention of absorbable 
material in the nasal fossae. Plugs of cotton or gauze are far inferior 
to vulcanite or metal tubes. When a broken nose has been neglected 
and fragments have become consolidated in a false position it is not 
easy to restore the normal contour of the nose. It is necessary to 
refracture the nasal bones, and for this purpose Walsham has de- 
signed a powerful forceps, one blade to be applied externally and 
the other internally. This involves more or less contusion of the 
skin, to obviate which J. O. Roe advises intranasal dissection of the 
skin from the surface of the bone and applying both blades through 
the nostril. E. J. Senn advocates exposure of the nasal bones by 
an incision along the dorsum of the nose and dissection of the soft 
parts. The bones are then broken with a small chisel, mobilized and 
shaped by means of a padded elevator introduced through the nos- 
tril, and held in place by passing a needle armed with silver wire 
transversely under the fragments, the ends of the wire then being 
attached to disks of lead, or preferably cork or other pliable sub- 
stance. The disks should be well padded with gauze. Intranasal 
splints of rubber tubing are inserted, the external wound is carefully 
stitched with fine sutures, and over all a plaster of Paris mask is held 



FRACTURE OF THE NOSE. 133 

with adhesive strips. The wire is withdrawn in five or six days, the 
tubes and the plaster mask in fifteen to eighteen days. An ingenious 
device by W. W. Carter seems to be based on sound mechanical 
principles and is especially adapted to deformities from old fracture, 
disease, or maldevelopment. The apparatus consists essentially 
of a bridge composed of two curved wings hinged together under 
control of a thumb-screw and padded with rubber where their 
margins rest on the sides of the nose. A perforated hard rubber 
splint for each nostril is adjusted, after the parts have been thor- 
oughly mobilized, by means of sutures of No. 14 iron-dyed silk, 
passed through the perforations in the splint and with a curved 
needle through the dorsum of the nose. The free ends of the silk 
are fastened through fenestrae in the external bridge and traction 
made to lift the dorsum to the desired extent. 

In many of these cases the nasal bones are not involved, but the 
septum is distorted and thickened, the redundant tissues permitting 
a resort to a series of subcutaneous plastic operations like those 
described by Roe. A transverse depression of the dorsum below the 
nasal bones, or a marked divergence from the middle line of the 
tip of the nose may be thus corrected. In other cases, when the 
traumatism has been considerable, the train of events comprises the 
formation of a hematoma of the septum, followed by suppuration, 
perforation and more or less loss of tissue. Under such circum- 
stances it often happens that some kind of prosthetic device or an 
external plastic operation is required. In some cases of old fracture 
followed by saddle-back deformity the plan of making an incision 
along the dorsum or transversely above the alae and inserting 
a plate of metal, gutta-percha, or celluloid has been successful, 
while in others the foreign body provoked irritation and had to be 
removed. The subcutaneous injection of paraffin, to be referred to 
more at length in the chapter on Syphilis, is well adapted to these 
cases. Moszkowicz, in Gersuny's clinic, uses a mixture of solid 
and liquid paraffins in such proportion as to give a melting point 
of from 96. 8° to 104 F. More recent investigations by others 
indicate that this is a dangerously low melting point. Embolus, or 
displacement of the mass, is possible unless the paraffin be suf- 
ficiently solid. 



CHAPTER VI. 



NASAL POLYPI 



The term nasal polyp properly refers to a gelatinous swelling or 
tumor of the mucous membrane of inflammatory origin. Some 
authorities use it indiscriminately to include various forms of benign 
neoplasm. As a matter of fact, a true polyp is in no sense a neo- 
plasm, although for a long time it was wrongly called "myxoma." 
Attention has been drawn to the erroneous use of the latter term by 
Hopmann and Chiari, and in this country by Jonathan Wright. In 
some cases of long standing the proportion of connective tissue is in 
excess and gives to the mass a considerable density. Recent polyps 
have a pulpy character and consist in large part of fluid. This 
feature is so marked that the qualifying adjective "edematous" is 
used. In some respects a polyp develops like granulation tissue, 
cellular elements predominating. It grows more vascular, increases 
in size by its own weight and finally becomes distinctly pedunculated. 
The formation of cells and fibrous tissue goes on indefinitely, the 
serous infiltration progresses at the same time, until a mass resem- 
bling a new growth is presented. The process described presupposes 
the existence of inflammation, yet it is rather unusual to see a well- 
defined polyp develop in the course of an acute attack of rhinitis. 
As a rule, nasal polypi are multiple and are observed in both nostrils, 
more frequently in men than in women, possibly in consequence of 
the relatively greater exposure of the former to the causes which 
produce inflammation of the nasal mucous membrane. Although 
there is, perhaps, no special diathesis predisposing to polypoid 
formation it is not uncommon to find examples of the disease in 
several members of the same family. Nasal polypi are seldom 
seen in children; they are essentially a disease of adult life. 

The theory of Woakes that nasal polypi are a direct consequence 
of a "necrosing ethmoiditis" has met with much opposition and 
would seem to be conclusively refuted by those cases of polyp seen to 
spring from the surface of the nasal septum, or from the wall of a 

*34 



NASAL POLYPI. 135 

sinus, in which there is no suspicion of bone disease. Soon after 
its announcement Martin, whose histological studies furnished a 
basis for the theory, declined to accept it, and later Lennox Browne 
and Spencer Watson asserted that none of the clinical features of 
necrosis can be discovered in polyp cases. Baumgarten believes 
that necrosis is a frequent but not invariable accompaniment of 
ethmoidal suppuration, while Grunwald declares that polyps may be 
associated with empyema of any of the accessory sinuses and not 
exclusively of the ethmoid cells. Hajek combats the theory of 
Woakes and maintains that ethmoid disease is merely a late stage of 
inflammation extending from the surface, the process being favored 
by the relative thinness of the mucous membrane in the region where 
polyps are usually found. The osseous fragility mistaken for necro- 
sis may occur as resorption of previously compact bony tissue or as 
new formation of bone, and necrosis is a result and not a cause of 
deep seated inflammation. Cordes is of the opinion that polyps may 
or may not be indicative of sinus disease, that affections of the bone 
may be either primary or secondary, and that a tendency to recur- 
rence must be accepted as a sign of bone involvement. The 
evidence that sinus disease is an etiological factor in nasal polypi is 
far from convincing, although these conditions no doubt often 
coexist. In this connection the announcement by Lichtwitz and 
other observers of the discovery in the post-mortem room of many 
cases of pus in the antrum which gave no sign during life is of 
interest, and yet it is quite incorrect to assume that every such ac- 
cumulation of fluid should be regarded as a sinus empyema. 

Inflammatory processes in the ethmoid region vary in degree and 
may be superficial, may affect the medullary substance of the middle 
turbinate, or may involve the framework of the ethmoid labyrinth. 
The ease with which the deeper structures are invaded is ex- 
plained by the direct continuity found to exist between the mucous 
membrane and the medulla of the bone. The changes in the bone 
consist of new formation and resorption, thickening and rarefying 
osteitis, the two processes going on at the same time, one or the other 
usually being in excess, but neither occurring alone. The perios- 
teum is thickened and crowded with large nucleated cells. The 
surface of the bone is marked by depressions filled with large cells. 
many of which are multinucleated. The bone cells are abnormally 
large and numerous. At points where the process has reached an 



I36 DISEASES OF THE NOSE, THROAT AND EAR. 

advanced stage are found groups of osteoclasts surrounding areas of 
disintegrating bone undergoing absorption. 

The theory of bone origin of polyps has an advocate in Lambert 
Lack, who defines a nasal polyp as a localized patch of edematous 
mucous membrane dependent upon subjacent bone disease. Gland- 
ular elements are often very pronounced and not infrequently dilata- 
tion and cystic formation result from obstruction of a gland duct. In 
every case of polyp, whether moderate or extensive, examined by 
this observer bone lesions of the nature of rarefying osteitis and not a 
true necrosis were found. With the finger under general anesthesia 
spicules and loose pieces of bone embedded in soft gelatinous 
mucous membrane may be plainly felt. A probe is likely to pierce 
the friable tissue and come in contact with the bone, thus possibly 
giving a false impression of necrosis. In some cases of long standing 
it is discovered that the turbinate bone has undergone absorption, 
having been entirely replaced by a mass of pulpy soft tissue. In 
others more recent the interior of the middle turbinate bone gradually 
disintegrates and the cell in its anterior end expands and forms a 
bony cyst sometimes reaching extreme dimensions. The latter 
process, which has been described in another section, often occurs 
quite independently of polypoid degeneration in the mucous mem- 
brane and indeed the latter may be in a condition of advanced 
atrophy. 

The symptoms of nasal polypi, at the outset, are those of acute or 
chronic rhinitis and usually begin with what the patient himself calls 
"cold in the head." Instead of a disappearance of the obstruction 
as usually experienced after recovery from a cold the nasal stenosis 
is persistent. If one side is affected the patient may not suffer 
extreme inconvenience; but if both nostrils are involved mouth 
breathing results with its usual discomfort. Asthenopia or other 
ocular disturbances, reflex neuralgias, cough and asthma are among 
the disorders which nasal polypi are known to excite. In well 
developed cases the patient is conscious of a movement of a pedun- 
culated polyp during nasal respiration. If its pedicle be unusually 
long the polyp presents itself at the anterior naris and if its attach- 
ment becomes excessively attenuated it may be actually blown out in 
the use of the handkerchief. There is usually a profuse discharge 
of watery secretion and speech acquires the so-called nasal quality. 
The sense of smell is impaired or completely lost either from me- 



NASAL POLYPI. 137 

chanical obstruction to the admission of odoriferous particles or 
from degeneration of the mucous membrane of the olfactory tract 
with the contained nerve filaments. Accessory sinus disease may 
result from obstruction to the outlet of a sinus especially in cases 
complicated by bone involvement, or may itself institute a condition 
of the mucous membrane predisposing to edema and polypoid 
development. 

On inspection a mucous polyp appears as a bluish, opalescent, 
semi-transparent tumor frequently crossed by small blood-vessels 
and bathed in watery fluid with occasional flakes of purulent secre- 
tion. On puncture the fluid contents escape and the tumor shrivels 
up more or less. An apparent capacity for absorbing moisture is 
often noticed by the laity as the symptoms it produces are much 





Fig. 66. — Nasal Polypi. (Griinwald.) 

aggravated in damp weather. On examining with a probe the fact 
that it is pedunculated is readily demonstrated. A polyp situated 
at the posterior naris is more firm than one in the interior of the nasal 
fossa owing to the normal predominance of fibrous tissue in the 
former region. This is to some extent true of anterior polyps as a 
result of irritation to which the latter are subjected. In a large 
proportion of cases the favorite site of polypi is the margin or free 
surface of the middle turbinate body. When a sinusitis coexists 
they are often seen springing from the lips of the ostium maxillare. 
They rarely arise from the septum although adhesions may take 
place between a polyp and the septal surface. They may develop 
to such a degree as to displace the septum or expand the nasal fossa 
so as to produce considerable facial disfigurement. They are rarely 



I38 DISEASES OF THE NOSE, THROAT AND EAR. 

single and, in some cases, an immense number have been removed; 
under the latter circumstances the polyps were really compound, 
several being attached by a common pedicle. They are almost 
always associated with hyperplastic and later with atrophic changes 
in the mucous membrane of the turbinate bodies as well as of the 
septum. They may remain without decided change for a long 
period, but seldom disappear spontaneously (Fig. 66). 

The prognosis is good, provided the patient will submit to treat- 
ment of a character and for the time necessary to accomplish a cure. 
When polyps are symptomatic of sinus disease the prognosis is 
naturally less favorable, and a cure is dependent upon correction of 
the sinus trouble. The tendency to recurrence is marked unless the 
underlying inflammatory condition, or bone lesion, is capable of 
relief. 

The treatment consists in removal with instruments or destruction 
of the mass by cauterization. In former times it was a common 
practice to inject astringents into the substance of the tumor, such as 
preparations of iron, zinc, or tannic acid and more recently a solu- 
tion of ethylate of sodium has been recommended by B. W. Richard- 
son as being more effective than the other agents mentioned. A 
crude method of removing these growths in old times consisted in 
introducing a polypus forceps, seizing whatever happened to fall 
between its blades and by a process of twisting and pulling, drag- 
ging from the nasal fossa as much tissue as the instrument might 
grasp. It was a fortunate circumstance if the whole turbinate bone 
were not removed together with the polypoid mass. It is impossible 
by this method to operate with precision or safety and in consequence 
the forceps has been abandoned in favor of the snare except possibly 
in cases of very small circumscribed growths whose attachment can 
be clearly defined. 

The bleeding excited by avulsion of a nasal polyp usually pro- 
hibits any further operative interference for the time being, whereas, 
with the cold wire snare it is possible to proceed with such delibera- 
tion as to make the operation completely bloodless. The number of 
snares in the market is somewhat appalling. My own preference 
for ordinary routine work is Sajous' modification of the Jarvis in- 
strument (Fig. 24). In the Sajous snare the loop is held at the 
distal end of the stylet which permits more exact manipulation than 
with canulated snares in which the wires are fastened in the handle 



NASAL POLYPI. 139 

of the instrument and are sure to twist on attempting to turn the 
loop. The capacity of the Sajous snare is limited by its screw 
thread; in other words the loop cannot be larger than the thread of 
the screw will exhaust. In using the snare for very large polyps 
the Jarvis instrument which permits an unlimited expansion of the 
loop is preferable. This is especially true of polyps which project 
into the nasal pharynx and where the loop is to be manipulated with 
the assistance of the finger passed through the mouth behind the 
velum. In ordinary cases for routine work the straight Sajous 
snare is thoroughly satisfactory. The loop is introduced in a vertical 
position between the polyp and the septum, then turned horizontally 
and crowded over the base of the growth. Care should be taken to 
hold the instrument firmly after it has once been placed and the 
thumb-screw when the loop has become engaged may be turned 
slowly or rapidly at will or as the patient permits. Some prefer the 
hot wire ecraseur, but it seems better to cauterize if need be after 
removal of the polyp. In most cases cauterization is quite un- 
necessary and the danger of damaging healthy mucous membrane 
with the heat should not be lightly considered. It is well to co- 
cainize the parts as thoroughly as possible before adjusting the loop, 
although it is difficult in these cases to get satisfactory anesthesia, 
and inconvenience from hemorrhage is greatly reduced by the use 
of suprarenal extract. 

Many operators prefer an angular snare in order to preserve an 
unobstructed operative field. In those cases of nasal polyp in which 
the turbinate body itself, including the bone, must be in part sacri- 
ficed, division of the structures should be very slow and any super- 
fluous weight in the instrument is objectionable. It is an advantage 
to have as little metal in the snare as may be consistent with strength. 
From the standpoint of treatment Lack divides polyp cases into 
four classes, (i) Those in which the polyps are few and the process 
in the bone has subsided. Removal with the snare effects a per- 
manent cure. (2) Cases of incipient bone disease with enlargement 
of the turbinate and edema of the mucous membrane. Here the 
anterior end of the bone, or as much as may be necessary, is to be 
removed. (3) Cases more advanced than the preceding in which a 
few polyps and a limited area of bone disease are present. In addi- 
tion to the snare, the loop of which should be adjusted as high as 
possible around the base of the growth, cutting forceps and the ring 



140 DISEASES OF THE NOSE, THROAT AND EAR. 

knife for curetting are useful, the latter being employed under ni- 
trous oxide anesthesia and good illumination. (4) Cases of exten- 
sive bone disease and multiple polyps. A radical operation under a 
general anesthetic is indicated in this condition. A spoke-shave, or 
forceps, is used for removing the principal masses, a large ring 
knife, or Meyer's adenoid curette, is recommended for completing 
the operation. The scraping should be done cautiously, especially 
in the region of the cribriform plate, the morbid tissues being iden- 
tified from time to time by digital examination. Healthy tissue is 
smooth, firm and resistant to the knife as well as the finger. If the 
posterior part of the ethmoid is to be attacked the nasopharynx is 
first tamponed, and in all cases the operation is done with the 
patient turned well over on the side. On the completion of the 
operation the nostril is packed with gauze soaked in glycerin-iodo- 
form emulsion, the dressing being changed and the nose irrigated 
every two or three days. Uniformly good results are claimed for 
this mode of operating, which presents decided advantages over the 
tedious nibbling operation in common practice. Some ecchymosis 
about the eye is a not unusual sequence. A suppurative otitis is not 
more common after this than other procedures and cerebral compli- 
cations have never been noted. Febrile reaction, especially frequent 
in sinus cases, subsides on withdrawal of the packing and a resort to 
nasal irrigation. 

In elderly people and in individuals with organic disease or a weak 
constitution, intranasal surgery of even moderate severity is often 
followed by alarming reaction. An operation of the magnitude of 
that just described involves an intolerable degree of shock and milder 
methods in repeated sittings must be referred. In fact, the pro- 
portion of cases in which such extensive sacrifice of tissue is de- 
manded is extremely small, although there are doubtless inveterate 
and recurring cases which can be cured in no other way. 

The after-treatment of polyp cases is very simple and should be 
limited to the use of cleansing and antiseptic sprays. Hemorrhage 
is rarely so free as to require special attention, but occasionally a 
firm tampon is necessary. The patient should be kept under obser- 
vation for some time in order to meet the first indications of recur- 
rence and to correct the catarrhal condition invariably present. 



CHAPTER VII. 

BENIGN TUMORS AND MALIGNANT DISEASE OF THE NASAL FOSS^. 
FOREIGN BODIES. RHINOLITHS. EPISTAXIS. 

Fibroma of the nasal fossa is one of the most unusual of neo- 
plasms. In the naso-pharynx it is more frequent owing to the fact 
that fibrous tissue is more plentiful at the upper and posterior parts 
of the nasal cavity and in the vault of the pharynx than elsewhere 
in the upper air tract. The admixture of fibrous tissue in sarco- 
matous and other tumors is not infrequent; but a pure fibroma is 
rare (Fig. 67). 

The degree of nasal obstruction caused by a fibroma depends upon 
its location and dimensions. The tumor is usually smooth, round, 




Fig. 67. — Section of Nasal Fibroma. (Author's specimen.) 

symmetrical and of a darker color than an ordinary polyp, and 
much denser in structure. It is usually distinctly pedunculated 
and can hardly be mistaken for a tumor of any other character 
except possibly an old nasal polyp. 

A case of pure fibroma of the nasal fossa came under my observation several 
years ago. It occurred in a young man of twenty-one who complained of catar- 
rhal symptoms and obstruction of the left nostril. There never had been any 
hemorrhage, the sense of smell was not impaired and the general health was 

141 



142 DISEASES OF THE NOSE, THROAT AND EAR. 

excellent. The patient had some cough with moderate expectoration, but there 
was no suspicion of pulmonary disease. On anterior rhinoscopy a movable 
tumor could be detected in the left posterior naris attached to the end of the 
middle turbinate. On posterior rhinoscopy the tumor seemed nearly to fill 
the left choana. It was smooth, round, symmetrical and darker in color than 
a gelatinous polyp, but was supposed to be a tumor of that kind containing an 
unusual proportion of fibrous tissue. It was removed with a cold wire snare 
without difficulty and with relief of the catarrhal symptoms. Under the micro- 
scope there was no trace of myxomatous tissue. The tumor was dense, non- 
vascular, and near its surface were collections of small round cells suggesting 
sarcoma, but doubtless of inflammatory origin. The fibrous structure was very 
marked especially at the center of the tumor. 

There is no difficulty in removing a nasal fibroma by the methods 
used in the treatment of nasal polyps, namely, with the cold wire 
snare, or if the pedicle is very thick and vascularity is suspected, the 
cautery loop. 

A fibroma of the naso-pharynx is a very different type of neoplasm. 
Many of the cases on record were undoubtedly mixed in structure 
and had a semi-malignant character. They are decidedly recurrent 
and many of the naso-pharyngeal fibromata reported were subjected 
to repeated operations before their final disappearance. Several 
of those on record were notably reduced in size by the use of electro- 
lysis. They are extremely vascular and an operation for their 
removal, when of large size, by the usual surgical procedures is so 
appalling that electricity offers a desirable substitute for the knife. 
In many cases the growths are so large as to necessitate division of 
the soft palate or even excision of the upper jaw in order to give 
satisfactory access. 

Among the rarer neoplasms met with in the nose may be men- 
tioned osteoma, enchondroma, angioma and cystoma. 

True papillomata, or warty growths, are of somewhat more fre- 
quent occurrence (Fig. 68) . There seems to be no doubt that some 
observers have mistaken simple hyperplasia of the mucous mem- 
brane for papilloma. Usually they appear anteriorly in the nasal 
cavity and they seldom attain very great size. They are more or 
less pedunculated and irregular in contour. They may resemble 
mucus polypi in color but are less smooth and regular. It may be 
difficult to establish a diagnosis without the aid of the microscope. 
Usually removal with the snare or scissors, followed by cauteriza- 
tion of the base, is successful in disposing of them. 



BENIGN NEOPLASMS OF THE NASAL FOSSvE. 143 

A bony tumor, or osteoma, in the nasal fossa is extremely rare 
and is usually unmistakable in character from the resistance it offers 
to the probe or exploring needle. Generally it is found to invade 
the nasal cavity from one of the accessory sinuses. It is a most 
serious lesion and can be reached, as a rule, only by an extensive 
external operation. 

Cartilaginous tumors are still more rare. They present symptoms 
very similar to those of osteomata and are handled in a similar way. 
An ecchondrosis, or inflammatory thickening of cartilage, is ex- 
tremely common and should not be confused with a chondroma, or 




Fig. 68. — Papilloma of Septum, Left Side. (Griimvald.) 

tumor composed of cartilage. The former involves the septum and 
seldom is seen in the young. A chondroma usually occurs early in 
life, is single, and is not necessarily connected with the septum. 

Nasal cysts have been observed in a very small number of cases, 
not more than three or four such having been recorded. Cystic 
changes in old nasal polypi are not uncommon. A simple retention 
cyst may be met with at almost any part of the upper air tract, 
while dermoid cysts are rarely seen elsewhere than in the nasal 
cavities. A genuine cystoma, or cystic dilatation of the normal 
lymph-channels, is usually found in adults and may develop at 
almost any situation. One case of the kind in my experience, in 
which the tumor occupied the floor of the nose in the left vestibule, 
was cured by free incision and packing the cavity with sterilized 
gauze. 

In spite of the fact that the Schneiderian membrane is highly 
vascular, angiomata very seldom occur in this locality. Doubtless 



144 DISEASES 01 THE NOSE,. THROAT AXD EAR. 

many cases reported as such have been confused with other neo- 
plasms richly supplied with blood-vessels. Xo cause for their 
development can be discovered, although it probably exists in some 
condition of malnutrition affecting the walls of the blood-vessels. 

The symptoms are such as would result from interference with 
nasal breathing and drainage added to epistaxis which may be severe 
or so frequent as to affect the general health. 

Pathologically these neoplasms consist primarily in a dilatation 
of the blood-vessels whose walls., supported by a network of con- 
nective tissue, become very much thinned and easily rupture. 
Angiomata may spring from a turbinate body or from the septum; 
usually they have been seen in the latter situation near the anterior 
nares, constituting the so-called '"bleeding polyp of the septum." 

Their appearance is characteristic. An irregular, elastic tumor 
of reddish or purplish color, from which hemorrhage is readily 
excited by rough handling, is seen attached to the mucous membrane 
by a broad base or a much constricted pedicle. It is of slow growth 
and there is no danger attending it aside from hemorrhage which may 
be prevented by the selection of a suitable mode of treatment and 
the avoidance of violence. 

Either the cold-wire or the galvano-cautery snare may be used in 
its removal. The loop should be adjusted well down upon the base 
of the tumor and should be tightened very slowly, especially if the 
cold-wire ecraseur be employed. Recurrences after thorough extir- 
pation are not usual. 

It is obvious that a srreat deal of confusion exists in the nomen- 
clature of intranasal neoplasms. For example, the term "papil- 
loma" has been erroneously applied by Hopmann and others to 
papillary hypertrophies. A genuine papilloma has definite histolog- 
ical characteristics which differentiate it positively from hypertrophy, 
or hyperplasia. Again simple varicosities, or vascular dilations of 
the blood-vessels of the mucosa, have often been wrongly called 
" angiomata. " In reading the descriptions of many cases of so- 
called "nasal fibroma" one cannot avoid the conviction that the 
tumors possessed a mixed character or were actually malignant. 
Moreover, some of these neoplasms originated in an accessor}* sinus 
or in adjacent structures and not in the nares. and hence cannot be 
properly classified as "nasal" fibromata. Those formidable cases 
in which occurs "'frog-face" deformity from expansion of the nasal 



BENIGN NEOPLASMS OF THE NASAL FOSS.E. 145 

bones, and violent hemorrhages take place, both spontaneously 
and when attempts at removal of the neoplasm are undertaken, are 
in this category and belong within the scope of general surgery. 

According to Lennox Browne the question of transformation of 
benign into malignant growth is settled in the affirmative. The 
testimony offered by one of his alleged cases, in which the patient 
himself "attributed his trouble to the frequent and long-continued 
introduction of a Eustachian catheter" is certainly far from accep- 
table. This distinguished authority asserts that " sarcomatous 
degeneration is most commonly witnessed" while epitheliomatous 
transformation is more rare. He cites several cases supposed to be 
confirmatory. An interesting and curious case was reported by 
Bayer in 1887. A villiform carcinoma was found implanted upon 
a base of innocent mucous polypoid tissue, but even in this case there 
remains a doubt as to which tissue was primary. A case of car- 
cinoma developing from a simple papilloma, under the observation 
of M. R. Ward, was thought to be proved by microscopic examina- 
tions to be a genuine example of transformation. 

In a most interesting case of adenocarcinoma reported by F. E. 
Hopkins, it is supposed that malignant transformation was provoked 
by violent manipulation, although the evidence is somewhat pre- 
sumptive. It appears that on three occasions, at intervals of a 
year each, attempts had been made to remove " myxomatous" 
tissue by forcibly dragging it out with polypus forceps. Symptoms 
of an intranasal growth had existed for many years and its benign 
character was inferred from the form, color and consistence of the 
neoplasm removed as well as from the fact that but slight hemorrhage 
followed the operation. No microscopic examination was made at 
this time. In commenting on this case Jonathan Wright remarks 
upon the rarity of lesions of the kind and upon the rapidity of 
their evolution, adenocarcinoma being somewhat slower than 
pure carcinoma. He has collected twenty authentic cases, discard- 
ing those not supported by microscopic testimony, a lack of which 
applies to more than half of those in Bosworth's list, but including 
several, like that of Beaman Douglas, of possible extranasal origin. 

Whether we accept these unusual instances as authentic, or. with 
Billroth, look upon the whole matter as a "traditional myth." the 
occurrence is not so frequent as to deter us from interference in 
suitable cases. 



146 DISEASES OF THE NOSE, THROAT AND EAR. 

MALIGNANT DISEASE OF THE NOSE. 

Malignant disease may have its origin in the nasal fossa, but fre- 
quently begins in adjacent structures and gradually crowds into the 
cavity of the nose. Carcinoma, presenting in the form of epitheli- 
oma, is rather more frequent than sarcoma according to Bosworth's 
figures, but in the opinion of J. S. Gibb, who adds 70 cases of sar- 
coma and 48 of carcinoma, "primary carcinoma of the nasal cham- 
bers is undoubtedly rare," while sarcoma is believed to be more 
common than statistics would seem to indicate, many cases remain- 
ing unrecognized and more not being reported. The latter is usu- 
ally of the round-celled variety and may occur at any age. The 
former is seen seldom before middle life. Men are more prone to 
the disease than women. The starting point of the disease may 
be in the antrum, and as the growth progresses tumefaction of the 
face appears, accompanied by occlusion of the nostril from pressure 
upon the nasal wall of the antrum, or protrusion of the mass through 
the ostium maxillare. Pain may not be pronounced until the dis- 
ease is far advanced, but there is apt to be at an early period a 
bloody discharge from the affected nostril. Free and even fatal 
hemorrhage may occur. 

In a case of fibrosarcoma reported by the author several years ago the tumor 
grew in all directions, finally invading the cerebral fossa and causing total blind- 
ness. In the meantime the growth had extended to the pharynx and impeded 
respiration. Previously on several occasions severe hemorrhage had taken 
place, spontaneously, and when attempts were made to clear the air tract by 
snaring off portions of the tumor. At length, during a fit of wild delirium 
consequent upon cerebral irritation, the patient thrust his fingers in his mouth 
and dragged out a large piece of the growth hanging over the margin of the 
velum. Immediately there was a fierce gush of blood from the nose and 
mouth and in a few hours the patient succumbed. It was impossible to deter- 
mine where the disease began, as it was first seen at a late stage and no autopsy 
was permitted. However, at a radical operation with removal of the upper jaw, 
undertaken by Weir several months before at the New York Hospital, it was 
found that the ethmoidal cells and the sphenoidal sinus were filled with neoplasm 
the limits of which beyond could not be safely traced. 

In view of the uncertainty regarding the implantation of 
malignant tumors of the nose it is an open question whether all 
cases of this kind should not be referred to the general surgeon for 
radical operation. Piecemeal removal with forceps and snare is 



lift 



MALIGNANT DISEASE OF THE NASAL FOSS.E. 147 

a superficial method which permits the base of the neoplasm to 
pursue its destructive invasion of adjacent parts. By many it is 
positively discountenanced (A. F. Plicque), while others are of the 
opinion that although no operation whatever is feasible in carcinoma, 
sarcoma is best treated by removal through the nose with the cold- 
wire snare (Bosworth). Of course the latter applies only when the 
disease is known to be strictly confined to the nasal chamber. In a 
case of this kind operated upon by Melville Black it was my privilege 
to watch the course of events several years subsequently. The 
growth involved the right middle turbinate and was removed with 
snare and forceps. Its sarcomatous nature was established by 
repeated microscopic examinations. More than ten years elapsed 
without sign of recurrence. Several weeks after a severe attack of 
typhoid fever obstruction of the nostril and nose-bleed led to an 
examination when unquestionable regrowth of the tumor was 
found. After some months' delay an external operation was done 
by B. F. Curtis who removed a large part of the naso-antral wall 
together with the neoplasm which occupied the middle turbinate 
region and had invaded the antrum. 

Implicit faith in the microscope as a guide in diagnosis is not 
advisable, at least as applied to sarcoma. A young woman once 
came to my clinic with stenosis of her right nostril. An extremely 
vascular tumor extending far back in the nostril was removed and 
quickly recurred. Microscopic examination pronounced it a sar- 
coma and all preparations were made to expose and remove the neo- 
plasm by an excision of the upper jaw, when she called attention to 
a tumor over the crest of her tibia. Under rapidly increasing doses 
of potassium iodide the periosteal node and the nasal sarcoma (?) 
disappeared simultaneously. Such experiences should not discredit 
the microscope nor the examiner. Different sections of the same 
new growth may present totally different appearances, and it is often 
impossible to differentiate a small round-celled sarcoma from a 
syphiloma. They should rather teach us to be cautious in accepting 
testimony derived from a single source in cases of this kind. When 
there exists the least doubt as to the nature of a neoplasm a tenta- 
tive antisyphilitic course of treatment is always indicated. 

The difficulty in diagnosis is often vastly augmented, especially 
in elderly patients, by the concurrence of malignant disease and sim- 
ple mucous polypi. The presence of the latter may obscure the 



148 DISEASES OF THE NOSE, THROAT AND EAR. 

case until in the process of clearing out the polyps with the snare we 
are startled by an alarming hemorrhage from an exceedingly 
sensitive growth, which proves to be malignant. Fetid discharge, 
hemorrhage and distortion of the face from intranasal pressure are 
seldom or never observed in gelatinous polypi and are invariably 
present earlier or later in malignant disease. 

In some cases neighboring bony tissues become affected. If the 
disease is located in the antrum the orbital plate is pushed up, forcing 
the eye from its socket, the skin of the face becomes adherent to the 
anterior wall of the antrum, which finally breaks down, permitting 
the protrusion of a fungous mass of vascular sensitive tissue. Cases 
which survive to this stage are most distressing from the disfigure- 
ment, the pain and the insupportable fetor attending the profuse 
ichorous discharge. The glands are seldom implicated. The 
development of epithelioma is much more insidious and rapid than 
that of sarcoma and may proceed without much pain or tumefaction 
until a late stage. Malignant disease may cause death by invasion 
of the cranial cavity, by exhaustion, hemorrhage, or metastasis, the 
last mentioned being more frequent in sarcoma. The record of 
results of operative interference is not encouraging, at least when 
the disease is so extensive as to require an excision of the upper jaw. 
According to H. T. Butlin, whose researches on this subject have 
been most thorough, the chief operative dangers are from exhaustion, 
blood-poisoning and pulmonary complications. He believes that 
unless measures to secure a better showing are feasible the opera- 
tion should be condemned. Recurrence is almost inevitable, and in 
any case malignant disease of the nose must be regarded as one of 
the most formidable and intractable with which we have to deal. 
This discouraging view is in a measure refuted by the brilliant results 
secured by Abbe in several cases of malignant disease which would 
ordinarily be regarded as inoperable. In one case in particular the 
right upper jaw and roof of mouth and part of the roof on the left 
side were removed, after a tracheotomy and ligation of both external 
carotids. This patient, a man 63 years old, was exempt from recur- 
rence five and a half years after operation, the effects of which, in 
part owing to a well-fitting plate, were scarcely perceptible. For 
details of the major operations the reader is referred to works on 
general surgery. In most cases we shall be called upon to rely 
solely on the free and constant use of anodynes. 



FOREIGN BODIES IN THE NASAL CHAMBERS. 149 

FOREIGN BODIES IN THE NASAL CHAMBERS. 

The introduction of a foreign body into the nose, either inten- 
tionally, accidentally, or in the act of vomiting, frequently occurs 
and may result in considerable disturbance. A one-sided purulent 
nasal discharge in a child is always suggestive of a foreign body. 
The objects children select are shoe-buttons, pebbles, or in fact any 
article small enough to be admitted to the anterior nares. 

As a rule, if no attempts have been made to extract the foreign 
body it is found lodged well forward in the nasal fossa. In many 
cases it is retained for years and in the meantime the patient is 
supposed to be suffering from nasal catarrh. Usually a purulent 
discharge is the only symptom and frequently its character is so 
acrid as to produce more or less excoriation of the nostril and lip. 
The pressure of a foreign body may cause erosion of the mucous 
membrane with which it is in contact and occasionally perforation 
of the cartilaginous septum results. In the event of laceration of 
the membrane the discharges show more or less admixture of blood. 
Syphilis may produce a one-sided nasal discharge but is attended by 
other symptoms which are confirmatory. Sinus disease generally 
causes discharge from one nostril but it is rarely observed in children 
and is seldom accompanied by obstruction to the nasal breathing 
which is usually a prominent symptom of a foreign body. 

A definite diagnosis can be made only by inspection and some- 
times by the use of the probe. It is necessary to cleanse the parts 
thoroughly of secretion and to apply cocaine, and, in young children 
and in nervous subjects, a general anesthetic may be required. As 
a rule, foreign bodies are within reach and can be extracted readily 
by means of a nasal forceps. Sometimes removal may be effected by 
passing a blunt hook, like a strabismus hook, behind the object. 
The loop of a cold snare is found to be useful. If the foreign body 
has slipped or been displaced into the postnasal space it is necessary 
to push it forward by means of the finger passed through the mouth 
behind the palate or it may be removed through the mouth. Sternu- 
tatories, the use of douches and the Politzer air-bag have been 
recommended for the removal of foreign bodies. The two latter 
methods are attended by more or less risk to the ears and, moreover, 
are less reliable than the nasal forceps. In rare cases in which the 
foreign body is of such a character as to imbibe moisture and in- 



I50 DISEASES OF THE NOSE, THROAT AND EAR. 

crease in size after its introduction, or in cases in which it has become 
impacted, it is necessary to do an external operation in order to 
secure more space for manipulation, or the object may have to be 
crushed and removed piecemeal. 

Many cases in which teeth have been found misplaced in a nasal 
fossa have been recorded. An interesting example noted by Krieg 
is that of a girl nineteen years old in whom the right lateral incisor 
"had lost its way upward" and was seen impinging upon the 
border of the inferior turbinate. Extraction would of course be 
indicated provided any subjective disturbance results from the 
anomaly. 

RHINOLITHS. 

A nasal calculus usually has a foreign body of some kind as a 
nucleus. A plug of inspissated mucus, or a coagulum, may furnish 
a base for the incrustation of salts. The shape of these calculi 
corresponds closely to the conformation of the nasal fossa. Some 
of those on record reached a most enormous size. 

The causes which induce them are not clear. It would seem 
probable that some malformation of the nasal passages must be in 
part responsible for them, possibly in combination with an obscure 
change in the character of the nasal secretion. They are found to 
contain the ordinary ingredients of nasal mucus with a large propor- 
tion of organic material and, in some cases, a small quantity of 
iron. 

As a rule, the symptoms are those which naturally would be ex- 
cited by a foreign body. In some of the more remarkable cases on 
record the disturbances were very profound. Distortion of the nose 
and hard palate and even perforation of the palate at its junction 
with the velum, facial paralysis, and ocular disturbances are 
enumerated. The discharge from the nose is almost always offen- 
sive, profuse and unilateral. 

The diagnosis is usually free from difficulty and is established by 
inspection and the use of the probe. 

The treatment is similar to that of a foreign 'body, although a 
calculus may be too large to be removed entire and must be crushed 
beforehand. The density of the mass is sometimes so great as to 
make this by no means easy. A small lithotrite has been found 
useful for this purpose. 



EPISTAXIS. 151 



EPISTAXIS. 



Nose-bleed may be traumatic, spontaneous or vicarious. Trau- 
matic nose-bleed may result from blows upon the external nose or 
from injuries to the mucous membrane from the introduction of 
foreign bodies, from violent blowing or sneezing, or from picking 
the nose. When the injury is of a serious character fracture of the 
nasal skeleton may involve the base of the skull and bleeding may 
arise from the ear as well as the nose, that from the latter being 
comparatively unimportant. In some cases the blood finds its way 
forward, but in young subjects or unconscious patients a consider- 
able quantity may flow backward and into the stomach, the persist- 
ence of the bleeding being finally betrayed by the occurrence of 
hematemesis or collapse. In post-operative hemorrhage one knows 
where to look for the source of the bleeding; otherwise, it is a matter 
of considerable difficulty to determine precisely its origin. 

Spontaneous nose-bleed may be symptomatic of an intranasal neo- 
plasm or it may occur in various constitutional conditions affecting 
the general circulation. It may be indicative of disease of the 
blood-vessels or of certain changes in the character of the blood 
itself which prevent coagulation. It is not uncommon in hemo- 
philia and several members of a family may habitually have nose- 
bleed. 

A sudden spontaneous nose-bleed in persons fifty years of age 
and upward ' should always excite suspicion of cardiac or other 
organic disease. This form of epistaxis has been carefully studied 
by George Coates, who finds the occurrence preceded by long- 
continued high arterial pressure and immediately by cardiac failure, 
either valvular or in the wall of the heart, accompanied by engorge- 
ment of the whole venous system. In these cases the indication is 
to relieve the turgid veins and the arterial pressure. After the capil- 
laries and arterioles have been dilated by agents like nitroglycerine, 
so-called heart tonics, strychnia and strophanthus, are useful. 
Plugging the nostril is seldom necessary and is generally futile. 
because the real difficulty is not in the nose. 

A very rare variety of epistaxis associated with multiple telan- 
giectases of the skin and mucous membranes has been reported by 
William Osier. The angiomata were in various regions, but espe- 
cially on the face which they much disfigured. In one fatal case 



152 DISEASES OF THE NOSE, THROAT AND EAR. 

they were found in the mucous membrane of the stomach, as well 
as in the nose, and the nasal septum was marked by numerous dilated 
veins. A relationship between telangiectases and hepatic affections 
is suggested, and obviously local measures, so far as the hemorrhage 
from the nose is concerned, can have only a palliative and temporary 
effect. 

Vicarious epistaxis has been observed in women whose menses are 
suppressed and in functional uterine disease. Epistaxis is a com- 
mon symptom in many exanthemata and fevers and is especially 
noted as an early symptom in typhoid. It is also a very frequent 
occurrence in diphtheria and is included among the symptoms of 
adenoids in the rhinopharynx. 





Fig. 69. — Swollen Granular Turbinates a Frequent Source of Epistaxis. (Krieg.) 

Fatal nose-bleed is an extremely rare accident and is hardly likely 
to occur except in hemophilia or in an individual already in a con- 
dition of extreme systemic depression. When confronted by a case 
of nose-bleed it is of the first importance to determine the source of 
the bleeding. It is not at all an unusual experience to meet with 
cases in which attempts to arrest the bleeding have been made by 
plugging the nostrils, whereas had the precaution been taken to de- 
termine the origin of the bleeding this disagreeable and somewhat 
dangerous process might have been avoided. In a very large 
proportion of cases a careful examination discovers that the blood 
comes from a turgid granular turbinate body, or much more 
frequently from (Fig. 69) an eroded point on the septal cartilage 
within a very short distance of the anterior naris and above the floor 
of the nose. This is referred to by some writers as "Kiesselbach's 



EPISTAXIS. 153 

spot," so named from an observer who has drawn especial attention 
to the small artery in this situation as a source of nasal hemorrhage 
(Fig. 70). Pressure exerted at that point fortified by the application 
of some styptic hardly ever fails promptly to control the bleeding. 
When the flow is very profuse, or is taking place in a patient nervous 
and frightened or young and obstreperous, it is no easy matter to 
keep the field clear long enough to discover the bleeding point; but, 
with a little patience, it is possible to see the blood ooze drop by drop 
or in a distinct "jet from the region referred to. In persons of 
advanced years with atheromatous arteries nose-bleed is a conserva- 
tive process and it is not to be hastily checked. The loss of blood 
may be considerable without doing a very great amount of damage 




Fig. 70. — Dilated Vessels on Septum in Region known as "Hartmann-Kiesselbach' 

Spot. (Krieg.) 



but, nevertheless, the alarm of the patient compels us to resort to a 
variety of measures for the purpose of checking the bleeding. 
Even if nothing were done in most cases a course of events similar 
to that observed in hemorrhage from other sources would doubt- 
less ensue; the bleeding persists until the depletion begins to pro- 
duce a sensation of faintness when the diminished blood pressure 
permits the formation of a coagulum to act as a natural tampon. 
Among the milder, measures used may be mentioned, raising 
the hands above the head, the application of ice, held in the mouth 
or placed in the nostril, or applied to the root of the nose either in 
the form of an ice-bag or gauze wrung out in iced water. In some 
cases hot water, at not less than 158 F., on pledgets of cot ion 
placed within the nostril seems to be effective, and is certainly an 
excellent way of stopping the hemorrhage which follows operative 



154 DISEASES OF THE XOSE. THROAT AND EAR. 

work. Hot water applied to the nape of the neck is said to have a 
decided effect. Various other domestic remedies have been used 
from time to time, but if these simpler methods do not avail and 
provided we cannot discover the isolated point of bleeding on the 
septum which has been described, plugging of the nostrils is necessary. 
In the first place an attempt should be made to control the bleeding 
by plugging the anterior naris and this is best done by means of 
narrow strips of sterilized gauze introduced far back in the nostril, 
successive layers being pushed in with a probe or nasal forceps. 
In order that packing from the front may be effective the gauze must 
not be more than half- or three-quarters of an inch wide, it must be 
carried as far back as possible and succeeding folds must be so small 
as to ensure a firm solid plug. The mistake is often made of at- 
tempting to put in too much at a time. This process is simplified 
by the use of the Darmack packer, a metal canula through' which 





Fig. 71. — Bellocq"s Canula. 



the gauze is pushed by means of a rod or piston. The gauze may 
be dusted with tannogallic acid powder, or soaked in a saturated 
solution. If bleeding still persists and the blood finds its way 
back to the pharynx, we shall be obliged to pack posteriorly as 
well as in front. The introduction of the posterior nasal plug is 
accomplished with Bellocq's canula (Fig. 71), or better by a flexible 
catheter passed along the floor of the nose until its end appears in 
the oro-pharynx whence it is drawn out through the mouth and a 
pledget of lint attached to it by one end of a strong double ligature. 
By pulling the catheter back again, the plug is drawn into the 
posterior naris. its passage being assisted by pressure from behind 
with the forefinger. It is important that the size of this plug should 
be correct; if too small, it is drawn into the nasal fossa; if too large. 
it becomes wedged in the pharynx and proves ineffective. Traction 
now being made on the anterior end of the ligature attached to the 
post-nasal plug, a tampon is put in so as to completely fill the nasal 



EPISTAXIS. 



J 55 



fossa. The plugs thus introduced should be removed not later than 
48 hours; if left in beyond that time, they are apt to become a source 
of danger from decomposition. Before attempting their removal 
it is wise to soften them thoroughly by soaking with oil or fluid 
vaseline. The nasal tampon is first removed and then the post- 
nasal plug by traction on the distal end of the ligature which 
has been left hanging in the pharynx. Wolff's posterior nasal 
tampon consists of eight layers of iodoform gauze twelve inches 
long and an inch wide to which are fastened five cords of stout 
silk in such a way as to draw the gauze into folds. Attached 
to a Bellocq canula the ends of the cords are pulled into 
the nose where by traction on each in succession the gauze is 
compressed into a firm plug. The nasal hemostat of A. Cooper 
Rose consists of a hard-rubber tube covered with a soft-rubber 
bag which after its introduction is dilated with air or water. 
It adapts itself to the irregularities of the walls of the nasal fossa 
in such a way as to exercise uniform pressure (Fig. 72). The 




Fig. 72. — Cooper Rose's Nasal Hemostat. 

withdrawal of the tube is effected by turning a stop-cock at its 
end and allowing the air or water with which the bag is inflated 
to escape. A similar apparatus is constructed out of a flexible 
catheter covered by a rubber hood. In treating cases of epistaxis 
too much emphasis cannot be laid upon the desirability of avoiding 
the so-called styptics, especially the iron preparations. In severe 
cases they are not only ineffective but they produce a very disagree- 
able mess in the nasal fossa and the hemorrhage which they are 
able to control would cease spontaneously. It is probable that the 
merits of "penghawar-djambi" an East Indian vegetable product 
highly lauded by Lubet-Barbon, Lermoyez and others, are due in 
part to the iron and tannin it is said to contain. It has a silky 
texture and its fine fibers in a tampon tend to favor formation of 
a clot quite independently of any hemostatic properties in the 
material itself. Hemorrhage of moderate severity may be cheeked 



156 DISEASES OF THE NOSE, THROAT AND EAR. 

by directing the patient to stand erect with both arms elevated 
above the head, in order to divert the blood pressure from the head 
to the upper extremities. If the bleeding comes from the septum, 
pressure upon the ala of the nose with the head thrown slightly for- 
ward will control it. In mild cases a spray of peroxide of hydro- 
gen into the affected nostril sometimes forms a sufficiently firm 
coagulum to stop the bleeding. A very excellent way of controlling 
bleeding when situated well forward and near the floor of the nose 
is by the introduction of the nasal plug of Bernays' sponge (W. K. 
Simpson), a flat disk of compressed cotton which absorbs moisture 
and expands to about three times its original thickness (Fig. 73). 
The hemostatic power of suprarenal extract is very striking, whether 
used locally or internally. Even in cases of hemophilia it is said 




Fig. 73. — Simpson's Plug of Bernays' Compressed Cotton. 

to have succeeded where other remedies had failed. It is important 
that fresh or aseptic solutions be used. Very unpleasant symptoms 
have followed the application of an infected solution. The fol- 
lowing method of preparing a reliable solution is suggested by 
W. H. Bates. One part of powdered suprarenal is mixed with 
ten parts of boiling saturated solution of boracic acid. It is then 
filtered and should be boiled daily before use. Thus prepared it will 
retain its properties for months, although it is somewhat less effec- 
tive than a plain watery solution. Under the name " adrenalin" 
the blood pressure raising principle of the suprarenal gland has 
been isolated in pure and stable form (Takamine) . All the extraor- 
dinary effects observed from the use of the extract are produced 
by this agent in magnified degree. A permanent sterilized 
solution of adrenalin chloride, 1 to 1,000, diluted with distilled 
water or physiological salt solution, gives us one of the most valuable 
of recent additions to our pharmacopeia. In hemophilia very 
striking results have been obtained from the internal use of calcium 
chloride or lactate. Yet by many they are discarded as useless. 



EPISTAXIS. 157 

Several cases of hemophilia in which the calcium salts failed showed 
marked improvement after subcutaneous injections of fresh rabbit 
serum (Weil) , and serotherapy is regarded with high favor by some 
in this alarming condition. 

Attention has recently been called to a rare source of hemorrhage 
in epistaxis by Brown Kelly, who describes several illustrative cases, 
after a careful study of the etiology of this form of nose-bleed. The 
anterior ethmoidal veins, from which the blood comes in these cases, 
anastomose with the veins of the dura mater and with the superior 
longitudinal sinus. Their close connection with the intracranial 
veins, and the absence of valves in their walls account for their 
tendency to bleed. The practical value of a recognition of this 
source of hemorrhage lies in the fact that the flow may be checked 
by firm plugging of the roof of the nose, leaving the lower part of 
the passage free for breathing. 

Whenever a localized hemorrhage can be defined, either from the 
septum, from the ethmoidal veins, or from an eroded turbinate body, 
it is better not to waste time by trying the various measures which 
have been described, but rather at once make direct pressure upon 
the spot from which the blood comes. An application of solid silver 
nitrate, or better the electric cautery, is generally efficacious and is 
certainly most satisfactory as regards the comfort of the patient. 
It is necessary to dry the bleeding point as thoroughly as possible 
with sterilized cotton and be prepared to make the application in- 
stantly on withdrawal of the cotton. Thus it is certain that many 
patients may be saved the discomfort and danger of plugging, a 
discomfort often amounting to pain both at the time and subse- 
quently, and a danger implicating especially the accessory sinuses 
and the ears. 

Without underestimating the significance of a nose-bleed it may 
be said that its importance is usually exaggerated and that most 
patients are unduly alarmed by its occurrence. 



CHAPTER VIII. 

SYPHILIS OF THE NASAL FOSS.E. LUPUS. TUBERCULOSIS. 
RHINOSCLEROMA. 

The primary lesion of acquired syphilis has been met with in 
several instances on record in the form of a small elevated papule 
soon undergoing ulceration which presents no special features by 
which it may be identified. A chronic indurated ulcer of the ala, 
of the turbinate body, or of the septum, accompanied by swelling of 
the submaxillary and sublingual glands, and a characteristic cutane- 
ous eruption, is always open to suspicion. In the second stage of 
syphilis we meet with mucous patches and with ulcerative processes 
either superficial or deep; in the latter case, the bone is apt to be 
affected and more or less extensive necrosis is followed by propor- 
tionate deformity. These deep ulcerations involving the frame- 
work of the nose are usually classed in the tertiary period and begin 
in the form of gummatous infiltration of the mucous membrane or as 
an inflammation of the bone or cartilage. In the former case the 
necrotic process in the hard parts is secondary to ulceration involving 
the mucosa and the periosteum or perichondrium. In the latter 
case death and destruction of bone or cartilage take place primarily 
and are followed by ulceration of the overlying mucous membrane. 
In some cases the affected bone instead of becoming necrosed and 
exfoliating undergoes a process of rarefying osteitis, or becomes so 
thickened as to obstruct the nasal passage, or, on the contrary, it 
may be absorbed. A syphilitic process sometimes invades a sinus, 
involves a nerve passing through one of the various foramina, or 
even extends to the meninges. 

Chancre and the early secondary lesions seldom require any 
special local treatment beyond cleanliness. They are usually pain- 
less and do not lead to extensive damage. The early recognition of 
gummatous infiltration in the nasal structures is of the utmost im- 
portance because of danger to the integrity of the framework of the 
nose and also because the earlier constitutional treatment is begun 
the more prompt is the response. Usually the symptoms are those 

158 



SYPHILIS OF THE NASAL FOSS.E. 1 59 

of ordinary coryza, and comprise sneezing, lachrymation, headache, 
impeded breathing and loss of smell. The secretions are free and 
watery and on inspection the mucous membrane is seen to be red, 
swollen and edematous. In the majority of cases the septum is chiefly 
involved and is so thickened as to cause more or less stenosis. On 
palpation with a probe the swelling is found to be less resistant and 
less hard than that of an ecchondrosis, or exostosis, but is sensitive 
and somewhat vascular. If the condition is not appreciated at this 
stage and controlled by proper treatment breaking down of tissue 
and destruction of bone and cartilage take place with surprising 
rapidity. In later stages we have presented the unmistakable 
odor of necrosis with profuse, bloody discharges which tend to in- 
spissate and adhere to the ulcerated surface in the form of dark 
greenish-yellow scabs. Small " worm-eaten" sequestra are extruded 
and if a probe be used the sensation of necrosed bone is obtained. 
Generally when the vomer has been lost by this process the nose 
becomes flattened and widened and very characteristic facial dis- 
figurement results, the so-called "saddle" nose. In some cases the 
external nose is involved by the ulcerative process or perforation 
into the cerebral cavity may take place. 

The question as to the management of a nasal sequestrum result- 
ing from syphilis is often presented and, in many cases, interference 
for removal of bone already dead and loose is permissible. As a 
rule, under active constitutional treatment a line of demarcation 
gradually forms and the bone affected becomes detached and may be 
removed without danger of damaging tissues that should be pre- 
served. In some cases, the sequestra are so voluminous that they 
cannot be extracted through the natural passages and we are com- 
pelled to resort to the operation suggested by Rouge, which consists 
in separating the upper lip by incision along the gingivo-labial fur- 
row and throwing up the alae of the nose in such a way as to expose 
the nasal fossae. If necessary, the margins of the vestibule are 
chipped with bone-forceps in order to give additional space. Al- 
though this operation appears formidable in reality it is found to 
be comparatively simple. The bleeding which occurs is generally 
controlled by pressure and after removal of sequestra the pans are 
simply replaced without the necessity of sutures or any special dress- 
ing. Various suggestions have been made looking to the correction 
of deformity resulting from syphilitic necrosis, among them the nasal 



l6o DISEASES OF THE NOSE, THROAT AND EAR. 

support of vulcanized rubber, suggested by Bishop (Fig. 74), and the 
artificial bridge of platinum or aluminum in the form proposed by 
Martin and modified by Hopkins (Fig. 75). My own experience 
with these devices leads me to believe that nothing of the sort should 
be undertaken until the patient has been subjected to a long course 
of specific medication and we are assured that his tissues are in such 
a condition that they will repair themselves kindly after operative 
interference; otherwise there is danger that the attempt to restore 
the contour of the nose may itself excite irritation and ulceration. 
The latter has happened in several instances in my own experience 
and a bridge has had to be removed, although, at first, the correction 





Fig. 74. — Bishop's Artificial Fig. 75. — Martin's Bridge 

Xasal Bridge. Modified by Hopkins. 

of the deformity was very gratifying and the apparatus gave no dis- 
comfort whatever. In its introduction the incision of Rouge is 
employed, the arms of the bridge, the shape and dimensions of which 
must be adapted to ..each individual case, being imbedded on either 
side in the superior maxilla. In certain cases, where the deformity 
is not extreme, it is found to be feasible to introduce a plate of 
platinum or celluloid underneath the skin, either by incision along 
the dorsum of the nose externally or by dissection of the skin from 
the dorsum by means of a sharp-pointed bistoury introduced through 
the nostril, the plate being pushed up into the pocket thus formed. 
In several cases in which it was necessary to remove a metallic plate 
the newly-formed connective tissue excited by its presence proved to 
give adequate support to a previously collapsed dorsum (Fig. 76). 

For the correction of these deformities the subcutaneous injection 
of melted sterilized paraffin, which may be molded to any desired 



SYPHILIS OF THE NASAL FOSSAE. 



161 



form and in time hardens to an almost cartilaginous consistency, has 
been practised on the suggestion of Gersuny. Sunken parts may 
be thus supported to the proper extent and the tissues are expected 
to tolerate the presence of suitably prepared paraffin much more 
kindly than they do a plate of metal. 

It appears that the first to use solidifying oils under the skin was 
J. Leonard Corning, of New York, who injected a mixture of paraffin 
and cocoa butter for the purpose of immobilizing a muscle to prevent 
spasmodic contractions. Almost instant consolidation of the oil and 




Fig. 76. — Martin's Bridge in Position. 

prevention of embolism were ensured by spraying the injected area 
with ether. Absence of local irritation and of inflammatory reaction 
in these experiments encouraged the use of the method for purely 
cosmetic purposes. It is important that the mixture should be 
thoroughly sterilized and that a combination of solid and fluid 
paraffin should be made giving a proper melting point (not less than 
io4°F.). If injected too hot and fluid there is danger of causing local 
reaction and thrombosis, and the mass does not become solid enough 
to give support. To keep the mixture fluid during the process of 
injecting a syringe surrounded by a soft-rubber sheath or hood as 
suggested by Eckstein, or by a hot water chamber like that proposed 
11 



l62 DISEASES OF THE NOSE, THROAT AND EAR. 

by Quinlan may be useful. An electric coil applied to the barrel of 
the syringe is perhaps more convenient. A rather large needle 
should be used and care should be taken to introduce the paraffin 
in a steady current. In several cases treated in this way by Harmon 
Smith at the Manhattan Eye, Ear and Throat Hospital a melting 
point of no° was used and five minims of a four per cent, solution of 
cocaine were injected before the paraffin. His experience with a 
syringe of his own device, the piston of which is worked by a screw 
movement, shows that it is possible to inject the mixture in almost 
solid consistence (Fig. 77). It is asserted by A. B. Comstock that 
the mass becomes organized and actually traversed to some extent by 



Fig. 77. — Harmon Smith's Paraffin Syringe. 

fibrils of connective tissue. The very exhaustive study of the 
behavior and fate of paraffin in various situations and under differ- 
ent conditions made by Luckett and Horn shows that actual organ- 
ization of the mass does not take place. Many factors are con- 
cerned, such as the temperature and consistence of the paraffin, the 
quantity used and the nature of the structures into which it is in- 
jected. In some cases it appears to break up into minute globules 
or granules, in others it becomes encapsulated, having undergone 
some shrinkage from absorption of its watery elements. The 
accidents recorded in connection with this procedure, sloughing of 
the skin, shifting of the paraffin, embolus in the lung, or in the eye 
causing permanent blindness, may be avoided by observing certain 
precautions. 1. The mixture must be perfectly sterilized and not 
too hot at moment of injection. 2. It must not be too fluid lest it 
be displaced. 3. A moderate amount should be injected at one 
time in order to avoid undue tension on the tissues at the site of 
operation. While the injection is being made and until the mass 
has been molded and become solidified it is well to make firm 
pressure at the root of the nose on either side. With care in these 
particulars it is possible to accomplish very satisfactory correction of 
deformity without risk. 



LU.II 



SYPHILIS OF THE NASAL FOSSAE. 163 

In many cases, however, loss of tissue and cicatricial contractions 
compel a resort to plastic surgery by the formation of flaps from the 
forehead, the cheeks, or other parts of the body. Nasal deformities 
due to syphilis are divided by Roberts into: (i) Those in which 
some part of the external nose has been ulcerated away; (2) those in 
which destruction of the septal cartilage has caused a transverse 
depression of the dorsum; (3) those in which in addition to the 
sinking of the dorsum cicatricial retraction of the alae or tip of the 
nose is present. Those included in the first group are most easily 
remedied, but much may be done even after extensive loss of tissue 
by judicious, well-planned operations. Very often a great deal of 
patience and a long time are required to accomplish much, but in 
view of the repulsive- deformity and the depressed mental state 
observed in these cases they certainly deserve careful study. The 
incisions in all rhinoplastic operations should be free enough to give 
a generous flap and to avoid tension, the resulting scars being much 
less disfiguring than the original unsightly deformity. 

In a few cases in which loss of tissue from specific disease has not 
been excessive the subcutaneous, or intranasal, operations described 
and very successfully practised by J. O. Roe are applicable, but in 
the majority the destruction has been so extensive that not enough 
material can be found within the nose with which to build up a 
supporting framework. 

The constitutional treatment of syphilis of the nose is that of the 
disease in general. Progressive doses of a saturated solution of 
iodid of potash are given in milk or vichy, half an hour after meals, 
beginning with ten drops, a drop or more being added to each dose 
until we get evident signs of iodism or indications of an impression 
upon the process going on in the nasal chambers. In the secondary 
and late lesions, especially if early treatment has been neglected, a 
combination of mercury with iodine is indicated, either in the form 
of the protoiodid, one-sixth of a grain three times a day, by inunction, 
or by calomel fumigations. The effects of intramuscular injections 
of mercury (salicylate) are said to be more prompt and accurate 
and some of the modern preparations of iodine (sajodin, iodalbin) 
are taken with less discomfort than sometimes follows potassium 
iodide. 

The use of alcohol should be prohibited and the patient should 
be put upon full diet, instructed to gel all the fresh air possible 



164 DISEASES OF THE NOSE, THROAT AND' EAR. 

and to use locally a douche or spray of DobelPs solution or some 
similar detergent. In nursing infants the nasal obstruction is a 
very serious matter. A few drops of adrenalin chlorid instilled into 
the nares usually succeed in opening the air tract, but it is clearly 
most important to get the patient under the influence of specific 
medication as rapidly as possible. In addition a tonic and suppor- 
tive treatment is often indicated. 



LUPUS AND TUBERCULOSIS. 

By many authorities lupus and tuberculosis are considered identi- 
cal, the former being looked upon as a modified or superficial variety 
of the latter. Their appearance, clinical history and general tend- 
ency differ sufficiently to justify a distinction. Many of their fea- 
tures are perplexingly similar, some resemble syphilis in certain 
points, while indications of mixed infection are presented in a small 
proportion of cases. 

Lupus occurs in the form of small nodules which coalesce and 
ulcerate, or absorption may take place, a feeble tendency to repair 
appearing at the margins of the lesions (Fig. 78). The nodules are 
very hard and distinct, hyperemic at first and becoming paler until 
finally they break down and ulcerate. The lesion spreads in a pecu- 
liar serpiginous way supposed to be characteristic. It usually begins 
on the anterior part of the septum, thence extending to the alae and 
the skin of the face, the formation of new nodules and of a typical 
bluish cicatrix going on at the same time. Sometimes the process 
is reversed, the disease beginning in the integument. The bony 
structures are never involved but the cartilages occasionally are 
attacked. One or both nostrils may be affected and there is more or 
less stenosis. The discharges at first watery become thick and fetid 
as ulceration progresses, with tendency to crust-formation. Pain is 
usually complained of, and the nodules and ulcers are quite sensi- 
tive to the touch. Sometimes itching is a prominent symptom. The 
deformity resulting from absorption of nodules and consequent 
atrophy or from cicatricial contraction is often extreme. The dis- 
ease is very resistant to treatment, although cases of spontaneous 
recovery have been met with. 

Nasal tuberculosis is very rare. It may be primary but is usually 
secondary to manifestations elsewhere. It occurs in the form of 



LUPUS AND TUBERCULOSIS OF THE NOSE. 1 65 

nodules or tumors of variable size which ultimately undergo ulcera- 
tion (Fig. 79). The secretions are free, thick and offensive and may 
be tinged with blood. Unlike those of lupus the nodules of tuber- 
culosis are insensitive and pale in color, and the ulcerative process 
of the latter does not spread in a serpiginous way and shows no 
tendency to repair. The crucial test in diagnosis is the presence of 
the tubercle bacillus, the bacillus of Koch. It is hard to find in the 





*0f®> 



Fig. 78. — Lupus of Anterior Nares (Gerber), showing lesions involving mucocutaneous 
junction and attempts at repair. 

scrapings but is pretty sure to be discovered in secretion of a tuber- 
culous tumor, or nodule. General symptoms depend upon the 
activity and extent of coincident lesions in the lung or elsewhere. 
Antisyphilitic treatment generally aggravates the local condition both 
in lupus and tuberculosis, and yet the use of mercury has recently 
been strenuously advocated in tuberculosis. If thought desirable 
the tuberculin test may be resorted to, a definite reaction generally 
being exhibited in cases of genuine tuberculosis, as well as in lupus. 



l66 DISEASES OF THE NOSE, THROAT AND EAR. 

Its value in detecting latent or incipient cases or confirming sus- 
picion in those giving no positive sign is unquestionable. Its use 
should be restricted to cases in which a diagnosis is of the utmost 
importance in order that vigorous measures may be taken to arrest 
the disease. Large doses, which involve corresponding violent 
local reaction, are not required and proofs are abundant that they 
encourage dissemination of the bacilli. But experience with smaller 
quantities, two to five milligrammes, seems to have demonstrated 
its innocuousness, and its reliability for diagnostic purposes. The 
diagnostic skin reaction with tuberculin ointment (Moro), the vac- 





Fig. 79. — Tuberculosis of Turbinates on Right Side and of Left Side of Septum with 

Perforations. (Gerber.) 

cination test (von Pirquet), and the ophthalmo-reaction (Calmette) 
are all attracting attention as safer substitutes for subcutaneous 
injection. Reports are conflicting as to their reliability, but there 
is reason to believe that they may prove of value. 

The tubercular tumor may appear on the septum or may select 
as its site a turbinate body; the tubercular ulcer, formed by the 
coalescence and breaking down of two or more miliary nodules 
generally begins at the anterior part of the septum whence it may 
extend to the external parts. Perforation of the septal cartilage 
may take place. It is difficult to make a diagnosis from the appear- 
ance of the ulcer which varies greatly in different cases. It may be 
round or ovoid, its edges may be flat or elevated, its surface may be 
smooth, covered with grumous secretion, dotted here and there with 
caseating tubercles, or obscured by masses of exuberant granulation. 

The treatment of lupus and of tuberculosis is conducted on similar 
lines. After careful cleansing of the parts all morbid deposit 



RHINOSCLEROMA. 167 

is thoroughly removed by means of the curette and the exposed 
area is then rubbed with pure lactic acid. The wound must be 
kept scrupulously clean with Dobell's solution or a carbolized 
alkaline wash, and if reaction and pain are excessive the surface 
is coated with an emollient ointment. One of the best is a mix- 
ture of orthoform with albolene or lanolin, a drachm to the ounce. 
General medication must be resorted to according to indications. 
In tuberculosis, as a rule, we are dealing, not with a local disease, 
but with a general diathesis, and the importance of good hygiene, 
pure air and sunshine, nutritious diet and supportive treatment is 
beyond question. Phototherapy seems to have been successful in 
lupus but not in tuberculosis. 

It is clearly proven that tubercle bacilli may be found in the 
nasal fossae of the perfectly healthy but especially of those attendant 
upon tubercular subjects, hence the necessity of care to avoid 
producing abrasion of the mucosa through which the germ might 
find entrance to the system. 

RHINOSCLEROMA. 

The opportunity of studying rhinoscleroma in this country is 
extremely rare. In 1893 Jackson could discover only three reported 
cases. Since then a few have been added to the list, with one excep- 
tion having been imported from abroad. This disease was first 
described by Hebra, whose account in some particulars is still ac- 
cepted as correct. It is a chronic inflammatory process involving 
the mucous membrane of the upper air tract, usually beginning in 
the nose at the anterior part of the septum, and sometimes extending 
thence to the pharynx, larynx and even to the trachea. It is char- 
acterized by extreme thickening and ivory-like hardness of the 
affected parts, which are sensitive to the touch but are free from 
spontaneous pain. It develops very slowly without edema or acute 
symptoms. It eventually causes great external deformity as well 
as internal distortion from cicatricial retraction and gradual filling 
of the passages with indurated masses. The tip of the nose becomes 
enormously broadened, hard and lobulated. When the pharynx is 
invaded the palate is thickened, leathery and covered with fine 
scales. The smooth nodular appearance of the external nose is 
compared by Kaposi to that of keloid. In some cases the course oi 



1 68 DISEASES OF THE NOSE THROAT AND EAR. 

the disease is reversed and it appears on the palate, in the larynx, or 
even in the trachea before any signs are present in the nares. The 
evidence seems to be almost convincing that a rare lesion described 
as chorditis hypertrophica inferior and what is known as Stoerk's 
blenorrhea are identical with rhinoscleroma. This view is held by 
Freudenthal, who has given a very careful and complete report of a 
case under his observation. The typical bacterium of rhinoscleroma 
is said to be the capsule bacillus of Frisch, resembling the pneumo- 
coccus of Friedlander, but not easily demonstrable. In a case 
reported by Roe, which is said to be the first instance of the disease 
originating in this country, it was difficult to find the bacilli in the 
cells, although certain bacilli were cultivated not unlike the pneu- 
mococcus. 

The treatment of the condition appears to be very unsatisfactory. 
The morbid tissue may be removed by the knife, or by curetting, or 
may be destroyed with the galvanocautery. Various chemical 
caustics, especially lactic acid, have been tried, with only temporary 
amelioration. Internal medication makes no impression on the 
lesion. In some cases the nodules soften and break down, as in one 
reported by C. W. Allen, in which almost the entire" mass sloughed 
away, exposing the bones of the upper jaw and the nasal septum. 
Generally the disease is extremely chronic, although the duration of 
Roe's case was only three and a half years. Its resemblance to 
malignant disease and the fact that the nose is often not its primary 
site have suggested the propriety of substituting the name " granula- 
tion sarcoma," or a similar title, for rhinoscleroma, which latter is 
manifestly inappropriate. In this connection Freudenthal suggests 
that good results may be possible with injections of Coley's fluid as 
in sarcoma, and he refers to the favorable reports of Pawlowsky with 
injections of rhino sclerene. In one case, that of Lubliner, the lesion 
absolutely disappeared after an attack of typhoid fever. 



CHAPTER IX. 

NASAL NEUROSES. HAY FEVER. NASAL HYDRORRHEA. 

Neurotic disturbances met with in the nose may affect the special 
sense of smell, or the secreting function of the mucous glands, or 
may excite certain reflex phenomena. 

Parosmia is a perversion of the sense of smell in which the subject 
perceives odors which do not exist. When the odor is offensive the 
term kakosmia is applied. It may be due to a pathological change 
in the nerve terminations or to some central nerve lesion. This 
phenomenon has been met with as a precursor of insanity and in the 
course of syphilis, hysteria and epilepsy. 

An exaggerated sense of smell, or hyperosmia, occurs in conditions 
of neurasthenia and in hysteria as well as in certain sexual derange- 
ments in women. 

Anosmia, or loss of smell, may be partial or complete and may 
result from injury or disease affecting the olfactory nerve or the 
nerve centers in the brain. It may be the result of some peripheral 
irritation, such as pungent gases or strong local applications to the 
nasal mucous membrane might produce. The sense of smell is also 
lost or impaired in simple acute and chronic inflammatory condi- 
tions, as a sequel of grip, and sometimes in connection with adenoids 
and polypi, or other lesions causing nasal obstruction. Finally loss 
of the sense of smell may be referred to functional or reflex disturb- 
ances. Thus anosmia is divided into three classes (Onodi). 
(i) Essential or true anosmia, central or peripheral, depending on 
the part of the olfactory nerve affected; (2) mechanical or respiratory 
anosmia resulting from atresia of the nares, congenital or acquired. 
Under this head are included conditions which prevent access of air 
to the nasal chambers, such as deformities, new growths and inflam- 
matory swellings; (3) functional anosmia, as in hysteria, and as a 
reflex from ovarian or uterine disturbance, from psoriasis" buccalis, 
and from cauterization of the inferior turbinates. 

The prognosis of anosmia depends in great degree upon its cause. 
Many cases even of long standing are benefited by treatment, or 

169 



170 DISEASES OF THE NOSE, THROAT AND EAR. 

recover spontaneously, especially when the condition is a sequel of 
influenza or neurasthenia. In advanced atrophy of the nasal mucous 
membrane the loss of smell is usually complete and permanent. 

Local treatment should be conducted with caution. In the first 
variety the mode of treatment is governed by the cause and its loca- 
tion. The relief of mechanical anosmia is generally feasible by 
removing the nasal impediment. In functional anosmia stimulation 
of the olfactory tract with galvanism and the internal use of general 
tonics are sometimes effective. 

HAY FEVER. 

Since the subject of reflex neuroses was first brought up an im- 
mense number of affections have been traced to disease of the nasal 
chambers. It must be admitted that many of these relationships have 
their origin in the imagination of the observer. In other words, a 
genuine nasal reflex is rare. The typical, most familiar example 
of a nasal neurosis is hay fever, at times accompanied by reflex 
asthma. It is otherwise known as hyperesthetic rhinitis, or period- 
ical vasomotor rhinitis, as well as by other titles. Three condi- 
tions are essential to its development, the neurotic temperament, 
nasal hyperesthesia associated or not with a deformity or neoplasm 
of the intranasal structures and, finally, an exciting cause in the 
shape of some irritant, either pollen, or emanations of some kind, 
animal or vegetable, or certain peculiar atmospheric states. By 
some a nervous temperament is not considered a requisite factor, 
the neurotic symptoms attending an attack being looked upon as 
a consequence rather than a cause. It is allied in many of its features 
to other neurotic disturbances, paroxysmal sneezing and similar 
phenomena known as autumnal catarrh and rose cold. These 
occur independently of any special period of the year and are some- 
times known as pseudo-hay fever. Rose cold is so called from its 
occurrence in June, the month of roses, although the attacks are 
not limited to that period. It is a well known fact that sneezing, 
cough, and lachrymation may be caused by irritation of certain 
areas in the nasal mucous membrane. It is possible to demonstrate 
with a probe sensitive regions but the idea that they are always 
to be found in similar situations in all individuals is erroneous. 
The influence of heredity as a predisposing cause is unquestioned; 



HAY FEVER. 171 

in at least half the cases of hay fever we succeed in getting a history 
of some neurotic manifestation in other members of the family. 
It is a curious fact that the disease seems to be limited to the Anglo- 
Saxon race and it is said to be more prevalent in males than in 
females. It is not always easy to discover the irritant which excites 
an attack. Dust of any kind, tobacco smoke, pollen of various plants, 
as rag-weed, or golden-rod, and emanations from certain animals 
are capable of producing it. The name rose cold is derived from 
the fact that symptoms of this kind are induced by roses, but the 
famous case of J. N. Mackenzie in which characteristic attacks 
were caused by an artificial rose proves that the phenomena may 
be of purely psychical origin. Many interesting cases are on 
record in which attacks closely resembling hay fever have developed 
in connection with renal irritation. Paroxysmal coryza of nephritic 
origin subsides with the relief of urinary symptoms and is not peri- 
odic but recurs if for any cause the renal derangement becomes 
aggravated. 

Haig, Bishop and others who have made extensive study of this 
subject, attribute hay fever to an excess of uric acid in the fluids of 
the body. Daly, Bosworth and others profess to find invariably some 
intranasal abnormality which acts as an exciting cause. Price- 
Brown traces the outbreaks to an antecedent hypertrophic rhinitis. 
Excessive alkalinity of the nasal secretions is thought to explain 
the condition in some cases. Paulty elimination and chemical 
changes in the secretions are regarded by some as prominent factors 
in etiology (Braden Kyle). Their existence is not to be denied, 
but whether as cause or effect remains to be determined. The 
argument in support of the uric acid as well as of the nasal stenosis 
theory of causation is measurably weakened by the fact that these 
states are very prevalent in those without a suspicion of hay fever. 
That they often coexist admits of no question; that they are occa- 
sional excitants is very probable. An attack is sometimes provoked 
by indiscretion iri diet and consequent digestive derangement. 
Extraordinary mental emotion or nervous excitement will aggravate 
or may even induce an attack. Certain localities seem to be 
relatively free from the disease and yet some sutler where others are 
exempt, and again the latter may succumb in a region where they 
have previously escaped. Hay fever usually occurs in adolescence 
or early middle life, but has been observed in children and even in 



172 DISEASES OF THE NOSE, THROAT AND EAR. 

infants. It is essentially a disease of the well-to-do, or of those whose 
affairs involve more or less nerve tension and excitement. Yet 
not a few cases have come to my notice in those whose lives were 
placid and free from care, but such persons have usually given a 
highly neurotic individual or family history. 

The symptoms of hay fever vary in different individuals and in 
the time when they appear. Usually the attack begins early in 
August and ceases with the advent of frost or cold weather. In 
some seasons the outbreak is delayed and occasionally its dura- 
tion is abbreviated, whence the inference that atmospheric states 
have an influence. One of the earliest symptoms is a sensation 
of itching and burning of the eyelids, particularly at the inner can- 
thus. Sometimes there is decided itching in the pharynx or roof 
of the mouth. This may persist for hours or days and is accom- 
panied by sneezing and suffusion of the eyes. The attack may 
come on with great abruptness or by degrees. Stenosis of the 
nostrils results from turbinate turgescence and presently a serous 
discharge begins which soon becomes remarkably free. Mental 
as well as physical depression, especially in very neurotic subjects, 
is pronounced. The eyelids frequently become very much swollen 
and there is marked photophobia. In some cases asthma super- 
venes, resembling, in all respects, the ordinary attacks of this affec- 
tion. Examination of the nose may show nothing more than would 
be expected in the early stage of acute catarrhal rhinitis, but the 
membranes are much less injected or are actually pale and soggy in 
appearance, and the serous effusion is much more abundant. In the 
interval of health nothing abnormal is found in the nose, or some 
deformity is discovered which may be reasonably looked upon as 
an aggravation if not the cause of symptoms. 

The prognosis as to the attacks is favorable; so far as the cure of 
the disease or the tendency to it is concerned, we cannot speak so 
hopefully except possibly in those cases in which we are able to 
discover a positive nasal lesion. The prognosis when little or no 
structural change can be detected and in individuals of highly neu- 
rotic temperament is decidedly less favorable. . 

In any case we are justified in promising some degree of ameliora- 
tion of symptoms as a result of treatment. Many patients prefer 
to secure exemption from the trouble by resorting to localities where 
experience has taught that they may be reasonably free from dis- 



LUfff 



HAY FEVER. I 73 

turbance. A sea voyage sometimes affords escape. Residence at a 
moderately high altitude appears to give immunity to some. The 
use of nerve tonics and sedatives is considered of value, and stimu- 
lants give temporary relief, but their use is not to be advised except in 
extreme cases. 

The importance of internal medication is urged by adherents of 
the uric acid theory as well as by many who find the first cause of 
hay fever in the nasal fossae. Without doubt cures have followed 
correction of nasal anomalies, yet the attention given to hygiene, 
diet, exercise and clothing, not to mention the use of tonics, by most 
practitioners shows that sole reliance is not placed upon local 
treatment. Bishop, who is a stout advocate of the uric acid idea, 
gives the acid phosphates (Horsford) in one or two teaspoonful doses 
night and morning, and never fails to stop an attack by a combina- 
tion of atropia and morphia in suitable cases, one part of the former 
to fifty of the latter, one-sixteenth to one-eighth of a grain of this 
mixture being given to an adult. Atropine has always been well 
thought of in asthma and seems to be especially adapted to that 
associated with hay fever. In extreme cases the addition of morphine 
may be desirable, but the use of such drugs should never be left to 
the discretion of the patient. Iodide of potassium, or sodium, or 
syrup of hydriodic acid finds favor with some, while others recom- 
mend strychnia in full doses, or the three valerianates of zinc, iron 
and quinine, one grain each. The internal use of thyroid extract 
has not been extensive enough to authorize a positive conclusion. 
The testimony offered by P. Heymann is favorable but not final. 
Sajous also commends desiccated thyroid in two grain doses twice a 
day for three days and then once daily, fortified by one-fiftieth of a 
grain of strychnia three times a day. The former is believed to 
enhance the "catabolism of toxic wastes"; the latter to "stimulate 
the vasomotor center and increase the oxygen intake." It is ap- 
parent that we have no specific for hay fever and in many cases the 
administration of' drugs does more harm than good. 

In these days when the accessory sinuses are attracting so much 
attention perhaps it is not surprising that they should be accused of 
joining the hay fever conspiracy. Accordingly we find E. Fink 
protesting that the sinuses, and especially the antrum, provide the 
secretion which is one of the prominent features of the disease. 
Insufflations of aristol made through the ostium are said to cure the 



174 

• 

most obstinate case. A degree of suspicion is thrown on the gen- 
uineness of this contention by the earnestness with which treatment 
of the coincident neurasthenia is urged. This idea has been 
adopted by J. E. Schadle who believes that irritation of the sensory 
and sympathetic fibers from the posterior dental, the anterior dental 
and Meckel's ganglion distributed to the lining membrane of the 
antrum, is the etiological factor in hay fever and in many cases of 
asthma. An essential predisposing condition is an abnormally large 
ostium, or a supplementary antral orifice, through which foreign 
particles are admitted with unusual readiness. It is thought that 
one with ostia perfectly normal in size and situation is not liable to 
these neurotic disturbances. The familiar phrase " unstable 
nervous organization " is invoked to help on the theory. The 
illustrative cases cited are neither numerous nor wholly convincing. 
The treatment based on the foregoing theory consists of thorough 
irrigation of the antral cavity through the normal opening, or an 
artificial opening in the inferior meatus, until the return fluid is 
clear and free of sediment, followed by applications of mentholized 
oil or insufflation of thymol iodide. The procedure provokes no 
objection and relief is said to be almost immediate in many 
cases. 

Bilateral resection of the nasal nerve has been recommended in 
rebellious cases of hay fever and in paroxysmal coryza (E. S. Yonge). 
The nerve may be reached by an incision curving from just above 
the inner canthus upward and outward to the anterior orbital 
foramen. The anterior ethmoidal artery having been separated 
from the nerve, about a quarter of an inch of the latter is resected 
close to its exit from the foramen. Anesthesia of the nasal mucosa, 
together with abolition of all hyperesthetic symptoms, is said to 
result. Even with the memory of misery still keen it is unlikely 
that very many sufferers will be persuaded to submit to a surgical 
procedure of this kind. A similar end is proposed in the use of 
intraneural injections of alcohol (Stein). On the theory that the 
fifth nerve is at fault its branches distributed to the mucous membrane 
of the nose are to be paralyzed by injections either externally within 
the orbit where the nasal nerve enters the ethmoidal foramen, or 
intranasally where the anterior division enters the nasal fossa through 
one of the cribriform perforations and in the sphenoethmoidal fossa 
near the posterior end of the middle turbinate where the posterior 



HAY FEVER. 175 

branch of the nerve is distributed. Experience with this method 
is still too limited to be reliable. 

Dry, hot air has been used with alleged benefit. The face of the 
patient is covered by a sort of hood, or basket, in which are en- 
closed half a dozen electric lamps (Hiirlimann). A special apparatus 
for projecting hot air would seem to be more convenient. 

Of local remedies nothing gives an equal degree of comfort as co- 
caine applied to the mucous membrane of the nose on a pledget of 
lint or in the form of a spray. It should never be entrusted to a 
patient, and when a strength greater than four per cent, is required 
for the desired effect its advantages are overbalanced by a detrimen- 
tal impression upon the nervous system. Moreover, its action is so 
transient that we are forced to conclude that its indiscriminate 
recommendation is not justifiable. The evils of the cocaine habit, 
a risk not to be ignored, are unhappily familiar. 

The extract of the suprarenal gland possesses astringent and 
hemostatic qualities, and is, at the same time, a tonic to muscle 
fiber. A great advantage of this agent is that it may be used 
liberally without ill effects. Not only is it free from toxic properties 
itself, but it seems to possess the power of limiting the toxic and 
prolonging the anesthetic effects of cocaine with which it maybe used 
in combination or alternately. 

A formula for a permanent solution which may be kept for several 
months is thus given (L. S. Sommers) : 

Adrenal 20 grains. 

Phenic acid 2 grains. 

Beta-eucain 5 grains. 

Distilled water 2 drachms 

M. Macerate for ten minutes and filter. 

The effect of the solution in blanching and retracting the mucous 
membrane is apparent at once, reaches its maximum in from three to 
five minutes, and lasts several hours. It causes slight smarting 
which soon subsides. In moderate cases a single application may 
give permanent relief. More immediate and pronounced results are 
claimed by some if the adrenal be given internally as well as used 
locally. One grain of the powder, representing eight grains of the 
fresh suprarenal gland, is given in tablet or capsule every two hours. 



176 DISEASES OF THE NOSE, THROAT AND EAR. 

until dizziness, or cardiac palpitation, develops, or the nasal mucosa 
shows the characteristic effects of the drug. For local use the 
following solution applied in spray or on cotton is satisfactory 
(E. F. Ingals) : 

Cocaine hydrochlorate gr. iiss. 

Soda biborate gr. v 

. Suprarenalin (1-1000) dr. i 

Glycerine dr. ss 

Camphor water oz. i 

A one per cent, aqueous solution of resorcin is said by Oppen- 
heimer to be an almost perfect preservative. 

A solution of suprarenal extract with chloretone is fairly perma- 
nent. Each minim represents one grain of fresh gland and the 
mixture contains 0.8 per cent, of chloretone. Adrenalin chloride 
mentioned in the chapter on Epistaxis has similar efficacy and is 
more stable. During the paroxysms of hay fever more or less 
comfort is derived from inhalations of camphor and menthol, equal 
parts in an inhaler, or in albolene solution so mild as to be quite 
free from irritating effects. 

In a small proportion of cases a weak solution of chromic acid, 
1/8 of a grain or less to the ounce of water, has been found efficacious 
in hay fever (Macdonald). A combination of muriate of quinine, 
1 drachm, glycerite of carbolic acid, B. P., 1 ounce, and perchloride 
of mercury, 1/1000 part (Andrew Clark), is useful in cases exhibit- 
ing no structural change. It is customary to cleanse the nostrils 
thoroughly, spray with cocaine in 10 per cent, solution, and then 
paint the mucous membrane of the nasal fossae with Clark's solution. 
Considerable burning is caused in spite of the cocaine, and for the 
next twenty-four or forty-eight hours a violent attack of coryza 
occurs. Massage of the mucous lining of the nose, or mechanical 
vibration, has been advised. The assertion is made by Alfred 
Denker that the attack is mitigated and recurrence prevented for 
several years by massage with a ten per cent, oily solution of euro- 
phen. The surfaces are first anesthetized with cocaine adrenalin 
solution and daily manipulations are practised for three or four 
minutes with gradually increasing pressure. The use of three 
different medicaments in this way leads to some confusion. 

In cases accompanied by structural anomalies or new growths it is 



HAY FEVER. 177 

possible to accomplish much more definite results than in others, 
Ecchondroses and exostoses of the septum impinging upon a turbi- 
nate act as exciting causes. Hyperplasia of the turbinate tissue 
in contact with the septum and nasal polypi are well known sources 
of irritation, and the removal of these various abnormalities is 
almost always followed by improvement if not absolute cure. 
Sensitive spots, identified by exploration with the probe, either upon 
the septum or the turbinate bodies, should be destroyed by the 
galvano-cautery or chemical caustics. 

The observation that the internal use of ipecac prevents the local 
effects of this drug in certain individuals has led to experiments 
with plants known to cause similar disturbances, especially the 
rag-weed (Holbrook Curtis). Some very curious results are 
recorded with tinctures and fluid extracts of golden-rod, lily of the 
valley and other plants. The contradictory reports made by 
different experimenters prove the large psychical element in these 
cases, which adds greatly to the difficulty of estimating the value 
of any therapeutic agent. The personal equation, both as to the 
patient and the observer, the possible number and variety of exciting 
causes, atmospheric conditions and other modifying influences 
must all be considered. The antitoxin treatment developed by 
Dunbar, of Hamburg, is still on trial. By some it is discarded, 
by others it is hailed as a specific. The truth may lie between, 
and at any rate too much praise cannot be accorded the zeal and 
honesty of investigations in this line. Under the name "pollantin" 
is offered a hay fever serum extracted from the pollen of various 
cereals. It is made in fluid and in powder, the latter being preferred 
on account of its superior stability. Only the antitoxin derived from 
the particular pollen causing the disease in a given case is expected 
to be efficacious. Failure to recognize this fact may be one cause 
of disappointment. The suitable "pollantin" must be selected 
and it should be used in moderate quantity, at the very outset of the 
attack. In addition we are urged to exclude the night air from sleep- 
ing-rooms and to avoid all possible sources of local irritation. X early 
all authorities agree upon the importance of these precautions, 
and it should be noted that their strict observance is often followed 
by amelioration of symptoms without any medication whatever. 
A preparation similar to Dunbar's serum, Weichert's "graminol," 
has been used with equally varied results. 



178 DISEASES OF THE NOSE, THROAT AND EAR. 

On the theory that some inhaled irritant is the chief exciting cause 
a "nostril filter" is recommended as a prophylactic by Mohr, and 
a similar contrivance is suggested by A. C. Heath. A lady under 
my care suffers much from golden-rod and dust of almost any kind, 
but is able to protect herself by wearing a damp cloth over the nose 
and mouth. Osteopathy worked wonders with her a year ago, 
while the past season it utterly failed and she had to resort to 
change of climate and keeping the nostrils annointed with a simple 
unguent like vaselin or lanolin. 

The tendency to attacks of hay fever and their severity seem to 
diminish with advancing years, and if immunity for several suc- 
cessive seasons can be obtained, if the nasal membranes can be re- 
stored to a condition of health and if, at the same time, the neurotic 
disposition can be modified we may hope for a disappearance or a 
mitigation of the disease. The prominence of the neurotic element 
varies greatly in different cases and in the same case in different 
seasons, but is never absent. In, some individuals attacks of 
sneezing occur on rising in the morning, on sudden exposure to 
bright sunshine, or after the ingestion of a hearty meal. A cure 
of these cases has been accomplished by hypnotic suggestion. 
Not every one is amenable to hypnosis, yet, contrary to the general 
belief that hypnotism is applicable only to "fools and weaklings," 
the experience of Lloyd Tuckey shows that "strong, muscular and 
intelligent men and women" are the best subjects. In many cases, 
however, a nasal lesion must be removed in order to obtain a per- 
manent cure. 

In spite of all that can be done the melancholy spectacle is all too 
frequent of an individual who has exhausted the resources of the 
general practitioner, who has experimented with every known quack 
nostrum, who has had most of his original intranasal structures re- 
moved by the ardent rhinologist and who still remains the unhappy 
victim of hay fever. 

NASAL HYDRORRHEA. 

A flow of watery secretion from the anterior nares under the name 
of nasal hydrorrhea is looked upon by some authorities as a modified 
form of hay fever. It occurs independently of season and is, un- 
doubtedly, a vasomotor affection. In some cases on record it seems 



NASAL HYDRORRHEA. 1 79 

to have been of malarial origin, occurring periodically, and accom- 
panied by chills and fever, a cure resulting from the administration 
of quinine. The few cases reported show great variation in clinical 
history, nasal discharge being the only fixed symptom. The quan- 
tity of secretion is more or less abundant, even a pint or more of 
fluid escaping in twenty-four hours, sometimes from one and again 
from both nostrils. It seems to have been observed in one instance 
as a symptom of general edema, in other cases associated with 
cerebral disease, and it has been seen in hysterical patients. Under 
these circumstances it is, of course, merely a symptom, in other 
cases the hydrorrhea is so pronounced as practically to constitute in 
itself a disease. A serous secretion from the nostril in nasal polpyi 
and in polypi of the accessory sinuses is very common, but under 
these circumstances must be placed in another category. In con- 
nection with trifacial neuralgia and certain genito-urinary disturb- 
ances in either sex it is purely a reflex disorder. The subjects of 
this affection are very sensitive to atmospheric conditions and 
the discharge is usually preceded by sensations of tickling in the 
nostrils and attacks of sneezing. 

It is usually met with in adults, the case reported by Cathcart in 
a girl nine years old being quite exceptional. 

Examination of the nose shows turgescence of the mucous mem- 
brane, which is redder than normal and is bathed in watery secre- 
tion. In cases of long standing the membranes become somewhat 
pale. There may be considerable nasal stenosis and paroxysms 
of reflex asthma may occur. 

If this affection is a symptom of a general diathesis it is obvious 
that local treatment alone cannot be efficacious. In view of the 
evidence of a malarial element the use of quinine is always indicated. 
Mustard foot baths with atropine and morphine internally have been 
known to check an attack. Violent local measures should be 
avoided, but relief may be obtained from applications of menthol in 
albolene or, if distress is extreme, by the use of cocaine. A more 
prolonged effect from adrenalin has been claimed in some cases. 
while in others it has utterly failed. Decortication of the nasal 
mucous membrane recommended by Moure and daily massage of 
the nasal fossae with cotton tampons soaked in borated vaseline and 
containing a little cocaine advised by Jankelevitch may be resorted 
to in the failure of other measures. The internal use of strychnin, 



*l8o DISEASES OF THE NOSE, THROAT AND EAR. 

hydrotherapy and the external application of the continuous electric 
current have each been found beneficial. Applications of hot air, as 
described in the chapter on Rhinitis, have been effective in the hands 
of G. Mahu, who seems to have "observed an extraordinary number 
of these cases. 

This condition must not be mistaken for the very rare phenom- 
enon which has been the subject of recent study, namely, the 
spontaneous discharge of cerebro-spinal fluid from the nose. Un- 
doubtedly some of the latter have been wrongly reported as cases of 
nasal hydrorrhea, and it is very clear that they have no relationship 
with hay fever. One of the earliest cases described was in a girl 
of fifteen who had hydrocephalus from birth (Leber). She had 
severe headaches, dizziness, and impaired vision and, finally, an 
epileptic fit which was followed by the continuous escape of fluid 
from the left nostril. 

In another case intermittent discharges from the nose were pre- 
ceded by severe headache, chiefly over the left eye, top and back of 
the head. When the flow was established the patient was relieved 
and appeared to be in perfect health in other respects (St. Clair 
Thomson) . 

In one case the discharge of watery fluid was preceded by very 
grave cerebral disturbance indicative of pressure as shown by the 
existence of optic neuritis and the occurrence of symptoms of tumor 
of the brain (Freudenthal). The flow was continuous night and 
day, in this respect differing from that of nasal hydrorrhea which 
usually stops at night. In the chemical analysis of the fluid, how- 
ever, we have a definite means of differentiating these conditions 
The chief points which serve to identify cerebro-spinal fluid are 
first, its clear watery character; second, its low specific gravity; 
third, the small amount of proteid in it and the absence of albumin, 
and fourth, the presence of a substance "possibly related to pyro- 
catechin which reduces Fehling's solution but is not dextrose." 
The history of these cases shows the importance of avoiding measures 
intended to check the flow, since cerebral symptoms recur almost as 
soon as any obstacle is offered to the escape of the fluid. It is re- 
markable that the leakage may continue indefinitely without any 
marked impairment of the general health. 



THE PHARYNX. 

CHAPTER X. 

ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 

The pharynx extends from the posterior nares to the cricoid car- 
tilage and is divided into three portions, the upper, or rhino pharynx, 
ending at the level of the palate, the middle, or oropharynx, extending 
to the vestibule of the larynx, and the lower, or laryngopharynx, 
leading into the esophagus at the lower border of the cricoid cartilage. 

The superior division has opening into it the orifices of the poste- 
rior nares, or choanae, those of the Eustachian tube on either side and 
below it is continuous with the buccal pharynx. Lesions in this 
division of the pharynx are of special interest from their relation to 
the Eustachian tubes, the sphenoidal sinus and the posterior nares. 
The orifice of the tube on either side is on a line with the inferior 
turbinate body and between them is sometimes found a mass of 
lymphoid tissue called the Eustachian or tubal tonsil. It is generally 
continuous with other adenoid vegetations on the wall of the rhino- 
pharynx and hardly deserves an independent name. The posterior 
lip or margin of the Eustachian tube is much more prominent than 
the anterior and forms a decided eminence called the Eustachian 
cushion. Behind it is a depression of considerable depth, the fossa 
of Rosenmuller, where large quantities of adenoids often accumulate 
and their removal with a large sharp-edged instrument is attended 
by some risk to the cushion. 

The middle division of the pharynx, or oropharynx, contains ag- 
gregations of lymphoid tissue between the pillars of the fauces known 
as the palatal or faucial tonsils, and similar masses at the base of the 
tongue called the lingual tonsil. The former present pathological 
conditions of great importance in both an acute and a chronic form. 
Acute disturbances of the lingual tonsil are less common, but the 
latter lymphoid mass often undergoes considerable enlargement and 
becomes a source of functional derangement affecting the pharynx 

181 



l82 DISEASES OF THE NOSE, THROAT AND EAR. 

and the larynx. The lingual tonsil also at times is involved in phleg- 
monous inflammation. Cases reported as abscess of the tongue are 
doubtless often a suppurative inflammation involving this structure. 
Across the base of the tongue we also see, especially in adults, a 
varicose condition of the blood-vessels quite independent of any 
special or marked change in the lymphoid tissue. An interesting 
and curious phenomenon at the posterior wall of the pharynx, 
visible through the mouth in the form of a pulsating vessel, has at- 
tracted a good deal of attention. It is either an abnormally placed 
ascending pharyngeal artery or a tortuous internal carotid as often 
seen in the aged. It is important only when we are called upon to 
use the knife in this region. 

The laryngo-pharynx, the third division, is of special interest to 
the laryngologist in connection with foreign bodies, which are apt to 
lodge at the point where the pharynx merges into the esophagus, and 
in connection with neoplastic formations invading it from the 
larynx. Many cases of dysphagia, or odynphagia, have their origin 
not in the swallowing track, but in the laryngeal cavity where com- 
pression by the inferior constrictor causes a feeling of obstruction or 
a sensation of pain. 

The pharynx measures from above downward about four and a 
half inches. Its narrowest portion is at its junction with the esoph- 
agus. Its lateral diameter is greater than its anteroposterior, being 
widest on a level with the cornua of the hyoid bone. Its wall is com- 
posed of a fibrous coat, the pharyngeal aponeurosis, which is lined 
by mucous membrane and surrounded by muscles, the pharyngeal 
constrictors. 

The pharyngeal aponeurosis is best marked at its upper portion 
where it is attached to the posterior part of the body of the sphenoid 
bone in front of the pharyngeal tubercle. Thence it runs outward 
to the apex of the petrous portion of the temporal bone to the car- 
tilage between it and the occipital bone to the Eustachian tube and 
the internal pterygoid plate. 

The mucous membrane is closely adherent to the base of the skull; 
in parts it is thick and spongy; in the neighborhood of the openings 
of the nares and Eustachian tubes it is thinner, while below it is pale 
and arranged in longitudinal folds. It is freely supplied with lymph 
follicles and racemose glands. Its epithelium is ciliated in the rhino- 
pharynx and becomes stratiform in the lower portion (Fig. 80). 



MUSCLES OF SOFT PALATE. 



183 




Fig. 80. — Muscles of Soft Palate Seen from Behind. (Denver.) 

a, Tensor palati muscle; b, salpingopharyngeus muscle; c, levator palati muscle, 
d, aponeurosis of soft palate; e, tensor palati tendon;/, tensor palati muscle; g } Eustach- 
ian tube; h, internal pterygoid muscle; i, external pterygoid muscle; ;. pharyngeal 
aponeurosis lining constrictors; k, lower jaw; /, palatoglossus muscle; m, palatopharyn- 
geus muscle; n, mucous membrane; 0, azygos uvulae muscle; />, posterior fasciculus 
of palatopharyngeus muscle q, tonsil; r, palatopharyngeus muscle. 



184 DISEASES OF THE NOSE, THROAT AND EAR. 

The muscles of the pharynx are the three constrictors, the superior, 
middle and inferior, fortified by fibers of the stylo- and palato- 
pharyngei muscles. The superior constrictor surrounds the upper 
part of the pharynx with the exception of a semilunar space on 
either side named the " sinus of Morgagni" which is filled in with 
the pharyngeal aponeurosis and contains the Eustachian tube and 
the levator palati muscle. It is quadrilateral in shape and arises 
from the lower third of the edge of the internal pterygoid plate and 
its hamular process, from the pterygo-maxillary ligament, from the 
posterior fifth of the mylohyoid ridge and the side of the tongue. 
The fibers pass backward to meet in the median raphe. 

The middle constrictor is fan-shaped and arises from the lesser 
cornua of the hyoid, from the whole length of the greater cornua, 
and from the stylo-hyoid ligament. Its fibers are also inserted into 
the median raphe. The upper ones overlap the superior constrictor 
and reach to the basilar process of the occipital bone, while the lower 
fibers are included within those of the inferior constrictor. 

The inferior constrictor is a thick muscle, very powerful, which 
arises from the thyroid cartilage behind the oblique line and superior 
tubercle as well as from the inferior cornua and from the sides of 
the cricoid behind the crico-thyroid muscle. The upper fibers over- 
lap the middle constrictor while the lower ones are continuous with 
the muscle fibers of the esophagus. Near its upper border the supe- 
rior laryngeal nerve and artery pierce the thyro-hyoid membrane. 
The recurrent laryngeal nerve enters beneath its lower border behind 
the crico-thyroid articulation. 

The stylo-pharyngeus arises from the base of the styloid process 
internally and passes downward and inward between the superior 
and middle constrictors. Its "fibers diverge, some joining the palato- 
pharyngeus to be inserted into the posterior border of the thyroid 
cartilage, and the rest mingling with the constrictors. 

The palato-pharyngeus forms the posterior pillar of the fauces. 
It arises from the aponeurosis of the soft palate by two heads sepa- 
rated by the insertion of the levator palati. The upper head blends 
with its fellow of the opposite side while the lower, which is the 
thicker, follows the curve of the posterior border of the palate. It 
also has its origin by one or two narrow bundles from the lower 
part of the cartilage of the Eustachian tube known as the salpingo- 
pharyngeus muscle. It is inserted by a narrow band into the pos- 



CONSTRICTORS OF PHARYNX. 






/- 




-* 






K 



FiG. 8i. — Constrictors of Pharynx. (Deaver.) 

a, Ophthalmic artery, b, internal carotid artery; c, sympathetic nerve; d, internal 
carotid artery; e, superior cervical ganglion of sympathetic; /, ascending pharyngeal 
artery; g, external carotid artery; h common carotid artery; /, lateral lobe of thyroid 
body; j, inferior thyroid artery; k, recurrent laryngeal nerve; /, trachea; ;;/, pharyngeal 
aponeurosis and sinus of Morgagni; n, buccinator muscle; o, pterygomaxillary ligament; 
p, superior constrictor muscle; q, raphe; r, stylopharyngeus muscle; s } middle eonstric- 
tor; t, greater cornu of hyoid bone; u, inferior constrictor; v, circular muscular fibers 
of esophagus; w, longitudinal muscular fibers of esophagus. 



1 86 DISEASES OF THE NOSE, THROAT AND EAR. 

terior border of the thyroid cartilage near the base of the superior 
cornu and by a broad expansion into the fibrous layers of the pharynx 
at its lower part (Fig. 81). 

The pharynx is separated from the vertebral column by the longus 
colli and rectus capitis antici muscles and by loose areolar tissue. 
Laterally it is in relation with the styloid process and its muscles, 
the glosso-pharyngeal nerve, the lateral lobes of the thyroid gland, 
the sheath of the carotid vessels, the pharyngeal plexus and the 
ascending pharyngeal artery. 

In the vault of the pharynx at its middle portion just below the 
body of the occipital bone is a pouch called the "pharyngeal bursa." 
It is the persistent lower portion of the pharyngeal diverticulum, the 
"pouch of Rathke," and usually disappears in adult life. 

Distributed over the wall of the rhinopharynx are numerous groups 
of lymphoid follicles comprising the "pharyngeal tonsil." 

The muscles of the pharynx are supplied by the pharyngeal plexus 
and the external and recurrent laryngeal nerves. The stylo-pharyn- 
geus is supplied by the glosso-pharyngeal nerve. 

The pharynx is of unusual interest and importance since it is con- 
cerned in four functions, respiration, audition, phonation, and 
deglutition. As an example of the importance of a normal pharynx 
to the act of breathing and the function of the ears it is only necessary 
to refer to the morbid condition known as "adenoids" in the 
rhinopharynx, in which "mouth-breathing" and various aural 
disturbances are conspicuous. 

Neoplastic growths, cicatricial contractions and malformations are 
met with in this region which may affect one or all of these func- 
tions. Aside from gross lesions it is necessary that the glandular 
apparatus of the pharyngeal mucosa should do its duty properly in 
order to furnish adequate lubrication for the lower pharynx in the 
act of swallowing. A resonant voice of pleasing quality can be 
produced only in the absence of deformity or anomalies in the 
pharyngeal wall. 

The uvula with the velum assists the epiglottis in shutting off the 
buccal cavity in normal nasal respiration, and helps to close the 
nasopharynx during deglutition. It also directs the nasal secretions 
toward the glosso-epiglottic fossae. When enlarged it frequently 
becomes a source of local or reflex irritation, while a considerable 
part of it may be sacrificed without detriment. On the other hand 



ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 187 

paresis of the palatal muscles, or a cleft of the soft palate has a pro- 
nounced effect both on speech and swallowing. 

The palatal or faucial tonsils are made up of a collection of 
follicles enclosing crypts or lacunae, ten to twenty in number, lying 
between the palatal folds and resembling in structure Peyer's 
patches. Their function has been the subject of much speculation. 
They were once supposed to furnish a lubricant for the bolus of 
food and again to absorb from the saliva certain particles as a 
pabulum for leucocytes. In a normal state they are not visible. 
Whatever their function may be they would seem no longer capable 
of exercising it when hyperplastic and diseased. It has been shown 
that leucocytes may migrate from the lymphoid tissue into the 
lacunae between the epithelial cells. Recent experiments have 
demonstrated that grains of carmin placed in the crypts appear later 
in the lymphoid tissue (Goodale). Similar absorption has been 
observed with various powders placed on the surface of the tonsils 
(Hendelsohn) and in the lower animals infection has followed rub- 
bing the tonsillar surface with streptococci. The foreign particles 
were found to have passed not only between but through the epithe- 
lial cells, the conclusion of Stohr that leucocytes pursue only the 
former course thus being opened to question. These experiments 
have a most important bearing on the conveyance of disease by 
infection, although they were conducted upon hypertrophied and 
therefore abnormal tonsils, and possibly throw no light on the 
function of normal lymphoid tissue. The latest investigations of 
this subject, with special reference to tuberculosis, show that the 
tonsils "as portals of infection" are no more susceptible than other 
portions of the mucous surface. In one hundred cases of pharyn- 
geal tonsil examined by Rethi, six of tuberculosis were found. On 
the other hand, in more than two hundred specimens of lymphoid 
tissue examined microscopically and bacteriologically by Goruc not 
one showed a giant cell, a tuberculous nodule, or a tubercle bacillus. 
A similar result was' obtained by Jonathan Wright in a series of 121 
cases examined with that observer's well-known care and skill. 
Undoubtedly, however, tuberculous infection may take place by this 
route without involving the lymphoid tissue itself, and several 
interesting experiences suggest that a latent tuberculosis may be 
excited to activity by operative interference with hypertrophied 
lymphoid tissue in persons previously unsuspected (Lermoyez and 



1 88 DISEASES OF THE NOSE, THROAT AND EAR. 

Chappell) . Yet the occurrence of the latter is so rare as not to con- 
stitute a valid objection to operation in these cases. The study of 
the subject up to the present time does not indicate whether normal 
is more or less prone than morbid lymphoid tissue to absorb patho- 
genic germs. The resistance offered to bacterial invasion by the 
epithelium of a child's tonsil as well as of an acutely inflamed tonsil 
in the adult, must be very slight, yet a condition of hyperplasia and 
especially of fibrosis seems to impede absorption. In a case recently 
observed by the author suppuration of the cervical glands compli- 
cating a follicular amygdalitis was followed by suppression of urine 
and other signs of renal irritation, attributable* to streptococcic 
infection. Such occurrences are not very uncommon and lend 
additional importance to simple inflammatory derangements of the 
pharyngeal structures. A case of primary tuberculoma of the 
nasopharynx recorded by Abercrombie is probably unique. 

METHODS OF EXAMINATION. 

The method of examining the rhinopharynx has already been 
described. Most of the oropharynx is within reach of the eye, yet 
even here a pharyngoscopic mirror is often useful. The probe is 
essential especially in examining pockets in the tonsillar region, and 
the index finger gives us valuable information as to the consistency 
of certain morbid growths and the mobility of neoplasms. Sharp- 
pointed foreign bodies often become engaged in the follicles at the 
base of the tongue or in the tonsillar crypts, where they may be 
detected by the finger when invisible to the eye. When the pharynx 
is very irritable, or the tongue arches and cannot be depressed by 
moderate force, a fair exposure of the parts may generally be ob- 
tained by directing the patient to take a deep inspiration and then 
sing a long "ah." Under ordinary conditions the walls of the 
laryngopharynx are in contact and are open to inspection only 
under the use of a dilating pharyngoscope. It has been proposed 
to examine the upper pharynx with the patient lying flat upon the 
back with the head well extended, the examiner standing at the head 
of the patient and introducing a large laryngeal mirror, the shank 
of which rests in the right angle of the patient's mouth instead of the 
left as usual. The awkwardness of the position and the satisfac- 
tory view generally obtained with the ordinary way of making an 



EXAMINATION OF THE PHARYNX. 150, 

examination of the upper pharynx will tend to prevent this method 
from becoming popular. Great advances have been made in our 
knowledge of the lower pharynx and esophagus as a result of studies 
by Mosher, Jackson, Killian and many others. At the present day 
these regions are brought directly under the eye for both explorative 
and operative purposes. In hypopharyngoscopy (von Eicken) the 
larynx is forcibly dragged away from the vertebral column by means 
of a stiff probe passed into or behind the cavity. The junction of 
the pharynx and esophagus, or "mouth of the esophagus" (Killian), 
is held firmly closed by muscular contraction and cannot be opened 
even by vigorous traction. At this point also the greatest resistance 
to the passage of a tube is encountered. A crescent-shaped lip^or 
fold of mucous membrane at the entrance to the esophagus is 
described by Killian and is surmised, together with the peculiar 
muscular arrangement, to bear some relation to diverticula or 
pouches of the pharynx developing late in life. 



CHAPTER XI. 

DISEASES OF THE VELUM AND UVULA. BIFID UVULA. NEOPLASMS 
AND MALIGNANT DISEASE OF THE VELUM. CLEFT PALATE. 
UVULITIS AND ELONGATED UVULA. ACUTE AND CHRONIC 
PHARYNGITIS. ATROPHIC PHARYNGITIS. RHEU- 
MATIC PHARYNGITIS. 

BIFID UVULA. 

Bifurcation of the uvula is a very common congenital mal-develop- 
ment. It is an elementary palatal cleft. The two divisions of the 
uvula are often quite symmetrical (Fig. 82). The furrow rarely 
involves the muscular tissue. It seldom has any importance except 
when one of the segments is so placed as to cause cough by tickling 
the pharyngeal wall. In such cases, unless the tissues are extremely 
redundant, the two halves of the uvula may be united^by denuding 
their opposed surfaces and bringing them together by means of one 




Fig. 82.— Bifid Uvula. 

or more sutures, or if the tissues are in excess one or the other of 
the subdivisions may be excised. 

Other malformations of the soft palate are sometimes seen, such 
as absence of the uvula or velum, asymmetry of the palatal arches, 
and perforations of one or both of the faucial pillars. Inequality 
of the sides of the palate may be congenital, independently of a 
paretic condition, while the latter is not infrequently observed 

190 



NEOPLASMS OF THE VELUM. 191 

as a sequel of diphtheria or as a symptom of cerebral -disease. 
Paralysis of the velum in non-diphtheritic nasopharyngitis of high 
intensity has been noted in several cases, among them one of my 
own, in which the loss of power persisted more than a month. 
Spasm of the velum, rhythmic or intermittent, may occur in con- 
nection with a general chorea, producing a distinctly audible sound, 
and more rarely in chronic rhinopharyngitis, causing what is de- 
scribed as "clicking tinnitus." 

Neoplasms of the palate, with the exception of the small warty 
growths often seen at the margin of the velum, are rather rare, 
although this structure may suffer by invasion from other parts. 
No satisfactory cause can be assigned for the development of new 
growths in this region. In several instances a neoplasm supposed 
to be a papilloma has proved malignant. A few cases of fibroma, 
of lipoma, and of angioma of the velum have been reported. A 
case of cyst of the right posterior pillar has been recorded by Jona- 
than Wright. Adenoma is more frequent and is often combined 
with other morbid tissue. It usually occurs in adults and has 
been seen more often in women than in men. Nearly all these 
growths may be safely and readily removed with knife, scissors, or 
snare, although some deeply embedded tumors require considerable 
dissection. With angiomata a cutting operation should be avoided. 
In a case of the latter once under my care the electric cautery worked 
admirably. The simpler forms of these benign neoplasms grow very 
slowly if at all, produce no inconvenience and may properly be left 
alone. 

Malignant disease appears in the form of sarcoma, or of carcinoma, 
the former, as in other situations, at almost any age, the latter 
usually in adult life. Owing to the scanty lymphatic circulation 
in this region glandular involvement is rather tardy. This fact 
combined with the relatively non-virulent tendency of sarcoma gives 
reason to hope for, good results from early surgical intervention in 
this disease. All kinds of sarcomata are met with. Their growth 
is slow and painless until ulceration develops. The chief symptoms 
relate to the function of the palate. Finally deglutition becomes 
impeded, an ichorous discharge occurs from an ulcerated surface. 
and hemorrhage, even fatal, may take place. It is often difficult 
to differentiate this lesion from epithelioma and it is always necessary 
to exclude syphilis by progressive doses of iodide of potash. 



I92 DISEASES OF THE NOSE, THROAT AND EAR. 

Epithelioma is more common late in life and in the male sex. Its 
evolution is rapid and highly malignant. Pain is an early and 
prominent symptom. Ulceration with fetid discharge, hemorrhage 
and glandular infiltration follow in order. Cachexia is usually pro- 
nounced. Surgical interference offers little hope and the Coley 
method of injection with the toxins of the bacillus prodigiosus and 
of erysipelas, sometimes effective in sarcoma, is not available. Local 
anesthesia with cocaine, nirvanin, or orthoform, detergent washes 
and general anodynes comprise all the resources at our command. 

Cleft palate and its appropriate treatment have been fertile topics 
for discussion many years. Space does not permit an exhaustive 
review of the subject, and in fact the condition is more apt to fall 
into the hands of the general surgeon than to the specialist. Suffice 
it to say that all shades of divergent opinion prevail with regard to 
its management, from one holding that mechanical correction of the 
defect is better than surgical intervention to the view that attempts 
at surgical closure should be undertaken in the earliest months of 
life. The technical details of uranoplasty seem to vary with the 
fancy of the operator. No less than twenty operations with slight 
variations bear the name of their respective promoters. Excessive 
tension on the flaps, disturbance of the wound especially by pressure 
from the tongue, and possibly septic infection have been recognized 
as interfering with the reparative process. The first is obviated by 
the formation of mucoperiosteal flaps by curved incisions in the hard 
palate along the alveolus on either side and by incisions carried well 
backward in the soft palate internal to the hamular process. An 
attempt to meet the last two difficulties is made in a method of 
operating in which a tracheotomy is done and after the cleft has 
been closed by sutures the oral cavity and the wound generally are 
firmly packed with sterilized gauze (J. F. McKernon). The 
trachea tube is retained for ten or twelve days, and the dressings 
are renewed each day, in the meantime feeding being carried 
on by the rectum. An objection to this plan from an aseptic 
standpoint appears in the fact that the salivary secretion is so stimu- 
lated that daily change of the dressings, with more or less disturb- 
ance of the wound, is necessary. The added risk of opening the 
trachea is not small and the irritation attendant upon a firm packing 
of the buccal and pharyngeal cavities is hardly compensated for by 
any improvement in results as compared with simpler modes of 



CLEFT PALATE. UVULITIS. ELONGATED UVULA. 193 

operating. The prognosis as regards defective speech is better the 
younger the patient. In older persons of sensitive organization the 
moral effect of being relieved of a deformity of this kind is very 
considerable, irrespective of other benefits. Defective speech after 
closure of a palatal cleft is due in part to muscular atrophy and in 
part to tension of the velum which the muscles are too weak to over- 
come. With a view to improving these conditions Makuen pro- 
poses first division of adhesions between the pillars and the remnant 
of tonsils, second forcible stretching of the velum with the finger 
after division of tense fibers of the palatal muscles, and finally train- 
ing and development of the palatal muscles by various direct and 
indirect voluntary exercises. Marked improvement has been ob- 
served in cases in which these procedures have been carried out, but 
it does not appear that perfectly normal speech is to be expected 
unless operative interference has been undertaken quite early in the 
formative speech period. 

UVULITIS. ELONGATED UVULA. 

Elongation of the uvula may result from frequent attacks of in- 
flammation involving the velum as well as the pharyngeal structures. 
It causes sensations of tickling or of a foreign body in the pharynx, 
which may lead to a dry persistent cough aggravated while the 
patient is in a recumbent position. Asthmatic attacks and even 
alarming glottic spasm may be induced by a long uvula. In a voice 
user the condition is most important and requires immediate cor- 
rection. In moderate cases astringents, such as nitrate of silver, 
or chromic acid, ten or twenty grains to the ounce, give relief. In 
some cases the general relaxed condition, due to anemia, should 
receive attention by the internal use of ferruginous preparations. 
In post-diphtheritic paralysis associated with a catarrhal condition, 
nerve tonics and electric applications are indicated, but no radical 
local treatment is required. Cases that resist these methods need sur- 
gical intervention and removal of the tip of the uvula, or staphylotomy 
must be done. Many instruments have been proposed, socalled 
uvulatomes, for this purpose, but it will be found quite as convenient 
to seize the tip of the uvula with the nasal forceps and remove as 
much as desired by means of the nasal scissors; the angle which 
these instruments possess carries the hands of the operator out of the 
13 



194 DISEASES OF THE NOSE, THROAT AND EAR. 

line of vision. Anesthria is obtained by the previous application of 
a 10 per cent, solution of cocaine. The tip of the uvula, being 
drawn somewhat forward, the line of incision is more or less oblique 
and the cut surface is thus made to look backward so that contact 
with food in swallowing is to some extent avoided. Bleeding is 
usually very slight and, in most cases, the pain of the operation and 
subsequent discomfort are not of much consequence. Now and 
then, however, bleeding is considerable and if not checked by as- 
tringent applications, requires to be controlled by a ligature, or the 
actual cautery, or as suggested by Carroll Morgan, by means of a 
clip like that attached to a garter. 

With the electro-cautery loop the tip of the uvula may be removed 
bloodlessly, but less quickly than with the uvulatome. The stump 
is perhaps a little more sensitive after a burning than a cutting 
operation. Occasionally after a uvulotomy in neurotic subjects, 
severe neuralgic pain is experienced, but usually with care as to diet 
all reaction subsides in forty-eight hours. It is well not to include 
the muscular tissue of the uvula in the section. Yet almost com- 
plete extirpation of this appendage is now and then witnessed with- 
out apparent detriment to the function of the velum. In the method 
followed by Braden Kyle a wedge-shaped piece is removed by cut- 
ting obliquely downward on either side from the middle of the 
uvula. Thus the shape of the organ is preserved, provided the 
segments be stitched together, and the stump is less sensitive. 

Acute uvulitis is generally an accompaniment of inflammation of 
adjacent structures or a pharyngitis. The uvula sometimes reaches 
the most extraordinary dimensions from edema, and in aggravated 
cases pain and obstruction to swallowing, or breathing, may be ex- 
treme. Multiple punctures of the swollen mass with a sharp- 
pointed bistoury permit the serum to drain off and encourage 
retraction. In moderate cases the effect of adrenal extract is said to 
be marvellous. Reference is made elsewhere to S. Solis-Cohen's 
extraordinary experience with an alarming edema of the velum 
following an application to the fauces of a suprarenal-chloretone 
solution. Such a phenomenon may be explained by a drug-idiosyn- 
crasy on the part of the individual or perhaps by some peculiarity in 
the constitution of the medicinal preparation. It may be necessary 
to excise portions of the relaxed and edematous tissue in order to 
give relief. Recovery is expedited by spraying the fauces with a 



ACUTE AND CHRONIC PHARYNGITIS. 195 

solution of tannin, or alumnol, ten to twenty grains to the ounce of 
water. Astringent gargles, or lozenges, are sometimes useful. 

"Edema of the uvula, often without very acute inflammatory 
symptoms, may occur in the gouty or rheumatic and in those having 
some renal derangement. In all such cases the condition of the 
kidneys should be especially investigated. 

ACUTE AND CHRONIC PHARYNGITIS. 

The mucous membrane of the pharynx is subject to inflammatory 
changes similar to those occurring in the nasal cavities. The upper 
division of the pharynx, known as the rhinopharynx, is part of the air 
tract and here we find important pathological processes involving 
the lymphoid tissue as well as neoplastic formations of interest. 
In the middle portion of the pharynx diseased conditions are of two- 
fold importance for the reason that the oropharynx is part of the 
food tract as well as of the air tract; hence, lesions in this situation 
may affect swallowing as well as breathing. The third division of 
the pharynx, or laryngopharynx, begins at the level of the arytenoids 
and extends to the lower border of the cricoid, is a portion of the 
food tract only and rarely falls under the eye of the laryngologist 
except as disease reaches it from the laryngeal cavity. Foreign 
bodies may be detained or neoplasms may develop in this region 
and thence invade the laryngeal cavity, thus involving the functions 
of deglutition, phonation and respiration. 

Inflammation of the pharyngeal mucosa may be acute or chronic. 
In the large majority of cases of so-called "cold-in-the-head" the 
prominent subjective symptom is a sensation of dryness referred to 
the region above the level of the soft palate. To the eve the surface 
appears dry, glazed and more or less swollen. This stage of in- 
flammation resembles that occurring in other mucous membranes 
and the course of events is similar to that observed in the nasal 
cavities. The soft palate and pillars of the fauces are somewhat 
swollen and edematous. In the course of a few hours serous 
exudation begins and if the process is very intense rupture of 
capillaries occurs and the secretion is stained with blood. Finally 
it becomes thicker and more viscid, and if fibrinous elements pre- 
dominate, as is apt to be the case in severe types of the disease, an 
exudate, or superficial false membrane forms resembling that of 



196 DISEASES OF THE NOSE, THROAT AND EAR. 

diphtheria but not infectious. This condition is sometimes called 
" membranous" pharyngitis. If the inflammation extends beyond 
the limits of the rhinopharynx pain in swallowing is extreme, other- 
wise in cases of moderate severity there is nothing more than a 
feeling of fullness or uneasiness in the throat. There is constant 
desire to clear the throat and to swallow. The degree to which the 
voice and the senses of smell and hearing are affected depends upon 
the intensity and extent of the pharyngeal inflammation. There is 
usually some fever and general disturbance and the patient may 
really feel quite ill. The prognosis, in the absence of complications 
in the form of some organic or constitutional disease, is good, the 
parts resuming their previous condition in the course of a week or 
ten days. In many cases, however, a chronic catarrhal condition 
results. 

The patient seldom attaches enough importance to his trouble to 
seek advice, so that we rarely see these cases early enough to do any 
good by efforts to abort the process. About all that can be done 
is to soothe the irritated parts by bland alkaline sprays followed by 
a protective coating of mentholized albolene, two to five grains of 
menthol to the ounce. Benzoinated steam inhalations are some- 
times grateful. Attention should be given to a gouty or rheumatic 
diathesis, as well as to possible derangements of the gastrointestinal 
tract, and a brisk purgative is often indicated. If the sufferings of 
the patient are considerable codeine or some of the coal-tar products, 
as phenacetin with salol, may be used cautiously. Belladonna, in 
the familiar rhinitis tablet, is sometimes useful. The local use of 
astringents is not to be recommended as they merely aggravate the 
discomfort. 

A very large proportion of chronic inflammatory conditions in this 
region are secondary to some lesion or deformity of the nasal 
chambers which first requires correction. A simple catarrhal 
pharyngitis sometimes yields to mild sedative or astringent applica- 
tions which have been referred to in speaking of the therapeutics of 
rhinitis; in cases which prove more rebellious it is necessary to look 
for some etiological factor within the nose or in the accessory sinuses. 
In not a few cases too of chronic pharyngitis the cause must be 
sought in the digestive tract. Dyspeptics almost invariably present 
more or less of an index of their condition in the mucous membrane 
of the pharynx. Occasionally we meet with an inflammatory 



CHRONIC PHARYNGITIS. 197 

condition involving chiefly the follicular elements of the pharyngeal 
mucous membrane constituting what is known as granular or 
follicular pharyngitis, or clergyman's sore throat, in which enlarged 
papillae, or hyperplastic lymphoid nodules are distributed at in- 
tervals over the surface of the membrane. The temptation to re- 
move these protuberances by means of the curette or destructive 
caustics should be resisted since, in many cases, the condition 
is symptomatic and radical measures directed to the local lesion 
encourage a tendency to atrophy of the mucous membrane and 
leave the patient more uncomfortable than he was originally. In 
some aggravated cases it is justifiable to touch the follicles with a 
chemical caustic, preferably trichloracetic acid, or the point of an 
electric cautery, care being taken to avoid making the application too 
extensive. On inspection of the fauces of certain individuals 
suffering from chronic pharyngitis there is seen in the middle of the 
pharyngeal wall an area of dry, glazed mucous membrane, dotted 
here and there with enlarged follicles and perhaps coated with a 
layer of tenacious secretion, and bounded on either side by a vertical 
band of red, thickened mucous membrane (Fig. 83). These lateral 
bands extend to the posterior pillars, which are themselves often 
much thickened, and they have been considered important enough 
to receive the independent title "pharyngitis hypertrophica lateralis." 
As a matter of fact they should always be looked upon as indicative 
of. disease in the vault of the pharynx or in the nasal chambers. 
According to the histological researches of Cordes the bands consist 
of collections of lymphoid follicles embedded in a fibrous reticulum 
and are analogous in structure to the palatal tonsils and to adenoids 
in the pharyngeal vault. It is clear that the remedy for them is to be 
found in giving first attention to the morbid condition higher up in 
the air tract which acts as the exciting cause. Adventitious bands 
running from the Eustachian cushion to the lateral or posterior wall 
and remnants of lymphoid tissue occupying the fossa of Rosen- 
muller are often found and are best removed with the finger-nail or a 
small curette. The accumulation of secretion in the nasopharynx 
is sometimes a source of annoyance which may be relieved by irri- 
gation of the parts by means of the postnasal syringe with warm 
alkaline solutions. Equal results are obtained in cases of irritable 
pharynx with more comfort to the patient from the use ol a menthol- 
ized albolene spray through the anterior nares. Xot infrequently 



198 DISEASES OF THE NOSE, THROAT AND EAR. 

annoying aural complications result from blocking of the Eustachian 
tube. When the aural symptoms are purely congestive, they are 
relieved to some degree by mentholated spray or applications of 
suprarenal extract to the vault of the pharynx. 

Inflammatory conditions in the nasopharynx are not infrequent 
complications or sequelae of the exanthemata and in the latter case 




Fig 83. — Chronic Follicular Pharyngitis and Hypertrophy of Lateral Bands. 

(Griinwald.) 

are benefited by general tonic treatment in combination with local 
applications. In all cases of "postnasal catarrh," especially of the 
class just mentioned, the possibility of sphenoidal or posterior 
ethmoidal disease as a source of the discharge should be investigated. 
A chronic nasopharyngitis is perhaps the most annoying and fre- 
quent of the morbid conditions with which we meet. The victims 
of it are burdens to themselves and sources of disgust to their 
neighbors from the constant hawking and clearing efforts demanded 
by the tenacious secretions accumulated in the vault. There 



CHRONIC PHARYNGITIS. 1 99 

is no doubt that many patients get into the habit of rasping their 
throats in this way quite unnecessarily. They should there- 
fore be urged to resist the desire as far as possible. In the treat- 
ment of this condition our main reliance is on the selection of a 
suitable astringent so applied after careful cleansing as to reach the 
whole surface. In some cases, a postnasal application must be 
supplemented by one made through the anterior nares. Sulphocar- 
bolate of zinc, 10 grains to the ounce, alumnol, 10 to 20 grains 
to the ounce, have, in my experience, proven the most agreeable and 
effective astringents. Nitrate of silver, 20 to 30 grains to the 
ounce, glycerol of tannin, or tincture of iodin, in cases of long 
standing in which the tissues are hyperplastic, may be more service- 
able. These agents are best applied with a probe, the tip of which 
is bent at a right angle and wound with cotton. Once or twice a 
week is often enough for the stronger applications, the daily use of 
the milder solutions being continued in the intervals. The treat- 
ment should always be preceded by thorough cleansing of the parts 
with alkaline irrigations by means of the anterior douche or the 
postnasal syringe. For the aggravated cases more powerful 
applications are indicated. Bosworth recommends undiluted 
monochloracetic acid and suggests lactic acid 30 to 60 grains 
to the ounce, or a guarded porte-caustique of his own device in- 
tended for fused chromic acid or nitrate of silver. These energetic 
measures are neither agreeable to the patient nor very efficacious, 
the authority just quoted admitting that results are unsatisfactory 
even from prolonged treatment. Internal medication has no 
specific effect but is often important in conditions of anemia, of 
gastrointestinal derangement, or in the gouty or rheumatic diathesis. 
Beverley Robinson speaks highly of cubebs internally with a view 
to rendering the mucous secretion more fluid and hence more easily 
disposed of. Alcohol except in very moderate quantities should be 
interdicted, and the use of tobacco, especially when the habit of 
inhaling the smoke is practised, should be restricted. The mode 
of life in general as to bathing, dress, exercise and diet must be 
supervised, but above all it is essential to remove an intranasal 
abnormality or obstruction which interferes with normal ventilation 
and drainage of the nasal tract. While excessive vigor in intra 
nasal surgery is to be deprecated, it is surprising to what extent 
distressing subjective symptoms are relieved by removal of an 



200 DISEASES OF THE NOSE, THROAT AND EAR. 

apparently unimportant nasal lesion. Such anomalies develop 
so gradually that the patient becomes accustomed to them and 
fails to appreciate their magnitude, whereas an equal degree of 
obstruction suddenly imposed -would be intolerable. After all has 
been done a certain proportion, unfortunately a large one, of these 
cases continue to be annoyed by the "dropping" in the throat and 
by their morning clearing out process, and after going from one 
specialist to another and one climate to another with possible tem- 
porary improvement settle down to the conviction that they are 
incurable. Ultimately nature takes charge of the case and with 
advancing years more or less mitigation of symptoms is experienced. 



ATROPHIC PHARYNGITIS. 

Pharyngitis sicca, or atrophic pharyngitis, is the result of an in- 
flammatory process induced by some local irritation, or is consecutive 
to a similar state in the nasal chambers. It may be associated 
with a constitutional condition characterized by malnutrition. 
The glandular secretion is perverted in quality and tends to adhere 
to the surface of the pharynx in dry scales or crusts, or as a thin 
film of inspissated mucus. On the other hand, sometimes the sur- 
face looks dry, thin and glazed, and has the appearance of having 
been varnished. The perverted secretion is itself a source of irrita- 
tion and leads to connective tissue cell proliferation and eventually 
a contracting process takes place which obliterates the blood supply 
and destroys the secreting glands. A great variety of bacteria are 
found in the secretions but there is no evidence to prove that they 
are, in any degree, an etiological factor. A subjective sensation of 
dryness, accompanied by burning or itching and a desire to swallow, 
are the most prominent symptoms. There may be some difficulty 
in swallowing owing to deficient lubrication or to rigidity of the mus- 
cles. In most cases the dry secretions are very tough and adherent. 
The patient is annoyed by a constant desire to relieve himself by 
hawking and even this does not succeed in dislodging the mucus. 
When the secretions have been cleared off the membrane is obviously 
thinner than normal and is very apt to be somewhat mottled, in cer- 
tain regions being congested, in others, pale. An unpleasant odor is 
imparted to the breath by the decomposing secretions. 



ATROPHIC PHARYNGITIS. 201 

The prognosis, as in atrophic rhinitis, depends upon the stage of 
advancement of the process. 

No treatment will restore glands that have been destroyed. But, 
if the disease is attributable to certain local irritants which can be 
removed and if the atrophy has not progressed too far, the results 
of treatment are more encouraging. Any associated nasal deformity 
or disease must be removed. The first essential, as in similar nasal 
disorders, is perfect cleanliness, which must be secured at the outset 
by careful and thorough use of an alkaline wash followed by a mild 
degree of stimulation; the latter is attained by the application of 
solutions of ichthyol or formalin. For the cleansing process a post- 
nasal douche or syringe, and in exceptionally tolerant cases a coarse 
spray are effective. The stimulating applications should be used 
with caution and their strength must be determined for each indi- 
vidual. At the conclusion of treatment the parts should be protected 
by spraying with a solution of menthol in albolene, about 5 grains 
to the ounce. By patient perseverence in this course much may 
be accomplished even in apparently bad cases, at least as regards 
the relief of distressing symptoms. Electricity in the form of 
faradism has been found of benefit, the positive pole being in 
contact with the pharyngeal wall while the negative is held in the 
hand of the patient (Seiss). The current is applied for two or 
three minutes with advantage. Galvanism, used as in nasal atrophy 
is beneficial. Massage, by means of a mechanical vibrator, 
or by hand with a probe wound with cotton, is of service. If 
desired the cotton may be moistened with thymol, iodin, or carbolic 
acid in oily solution. Sometimes one agent and again another 
seems to act more satisfactorily. 

Owing to occasional damage to the ears from the nasal douche 
its use is condemned by some, but with a bland alkaline detergent 
at proper temperature and if the patient is warned to let the fluid 
drain off gradually and not blow the nose violently with the nostrils 
compressed there is little or no danger. 

Internally we might expect good results from drugs known to 
influence glandular secretion, such as jaborandi, pilocarpin, or the 
iodid salts. Occasionally they appear to give temporary relief by 
supplying moisture to the dry surfaces, but they cannot be long 
continued without danger of disturbing the stomach. Careful at- 
tention should be paid to the digestive function and if necessary 



202 DISEASES OF THE NOSE, THROAT AND EAR. 

constipation should be corrected by the use of saline or other laxa- 
tives. Good hygiene and the general regime and treatment referred 
to in speaking of rhinitis are equally important in inflammation of 
the pharynx. 

RHEUMATIC PHARYNGITIS. 

The effects of the rheumatic diathesis upon the fibrous tissues of 
the pharyngeal wall are generally admitted but no definite local 
symptoms can be considered characteristic. Cases vary in their 
subjective phenomena and we have to rely on the general symptoms 
and on the rheumatic history in making a diagnosis. The general 
rheumatic disturbance, such as inflammation of muscles and joints, 
may not appear until after the pharyngeal symptoms have become 
established, or the latter may be secondary and insignificant. In 
most cases the local appearances are less intense than in ordinary 
acute pharyngitis and are abrupt in onset and disappearance. The 
pain in swallowing is out of proportion to the inflammatory appear- 
ances and is not influenced by the usual local remedies employed in 
simple tonsillitis or pharyngitis. It is usually met with at or after 
middle life and not infrequently follows exposure. Fatigue and 
depressed general health predispose to an attack. Relapses are 
frequent and it is noticed that outbreaks of the affection are 
common in the spring and fall of the year or after a decided fall of 
temperature. 

Local treatment is of little avail, although the application of heat, 
externally and by steam inhalations, is sometimes grateful. Cases 
usually respond as soon as the system is under the influence of anti- 
rheumatic medication. The salicylates, especially the salicylate of 
sodium in ten-grain doses every four hours, give the most satisfac- 
tion. If not well tolerated aspirin, or novaspirin, is preferable. 
Some cases seem to act better under the alkaline treatment, small 
doses of bicarbonate of soda, of sodium phosphate, or of Rochelle 
or Carlsbad salts being administered at short intervals. 

While it seems to be established that a very large proportion, 
according to St. Clair Thomson from 30 to 38 per cent., of cases 
of acute rheumatism begin with an angina, yet the local pharyngeal 
indications are indefinite. Apparently the parenchymatous or 
follicular form of amygdalitis, rather than the phlegmonous, 



RHEUMATIC PHARYNGITIS. 203 

or quinsy, is the rheumatic type. At any rate antirheumatic reme- 
dies are often effective in the former and are much less so in the 
latter. Possibly the rheumatic virus may enter the system by way 
of the pharynx, as is the case with other poisons, and leave no local 
indications. 



CHAPTER XII 

ADENOIDS IN THE RHINOPHARYNX. 

The name tonsil has been applied to various collections of lym- 
phoid tissue beside those between the palatal folds; at the base of 
the tongue is the Ungual tonsil; in the vault of the pharynx the 
pharyngeal tonsil; in addition, small masses in or near the ventricles 
of the larynx are called the laryngeal tonsils; and of still less im- 
portance the aggregations within the nostrils are known as the nasal 
tonsils. 

The collection in the vault of the pharynx, the pharyngeal tonsil, 
or adenoids, is perhaps the most important. It is a conglomerate 
gland, covered by thin mucous membrane and columnar epithelium, 
sometimes ciliated. It is a vascular body and, like the faucial ton- 
sil, is a normal organ which is disposed to undergo atrophy at about 
maturity. The idea that tonsils are normal bodies is vigorously com- 
bated by Bosworth, who contends that a visible tonsil is an abnor- 
mality and should be removed like any other tumor. No one at the 
present day is likely to affirm that an organ is " normal" which is 
itself diseased or may be the cause of morbid conditions elsewhere, 
yet it is often equally difficult to define the boundary between a nor- 
mal and an abnormal tonsil and to decide whether in a given case 
a mass of lymphoid tissue needs to be removed. Many diseased ton- 
sils are carried through life without detriment and the latter question 
hinges mainly on the degree of subjective disturbance they excite 
rather than on their dimensions or degree of abnormality. Nodules 
of lymphoid tissue are undoubtedly normal in certain regions. Per- 
haps we may admit the correctness of the view that "the tonsils 
are pathological entities when they can be demonstrated clinically," 
but that is very different from saying that all tonsils should be removed. 
The points to be determined are, first, whether the enlarged lymph 
nodes have ceased to perform their function, presumably that of 
defending the system against infectious germs, and, second, whether 
they are a cause of local or general derangement. 

The pharyngeal tonsil has been particularly described by the 

204 



ADENOIDS. 



20: 



German anatomist Luschka and is sometimes called "Luschka's 
bursa or tonsil," this name being restricted to the main aggregation 
of lymphoid tissue in the middle of the pharyngeal vault. A large 
crypt or lacuna in the midst of this bursa often ends in a dilated 
extremity which sometimes becomes distended by accumulation of 
secretion owing to obstruction of its outlet, thus forming a cyst of 
considerable dimensions which occasionally undergoes suppuration. 
It has been particularly studied by Tornwaldt and from him is known 




Fig. 84. — Adenoids in Rhinopharvnx. (Griinwald .) 

as Tornwaldt's disease, or cyst of the pharyngeal bursa. The 
pharyngeal tonsil, or adenoid vegetations, becomes of interest and 
importance in its enlarged condition from the obstruction it offers 
to nasal respiration, from disturbance it may excite in the ear by 
pressure in the region of the Eustachian tube or orifice, and from 
the causative relation it bears to various other disorders, reflex de- 
rangements as well as infectious diseases (Fig. 84). 

Adenoids are met with very early in life, if they are not actually 
congenital. They are always an impediment to health and in a 



206 DISEASES OF THE NOSE, THROAT AND EAR. 

nursing infant may be a serious obstacle to nutrition. They are 
seldom seen in adults, although several marked examples in very old 
subjects have been recorded. Remnants of lymphoid tissue and 
the evidences of the damage it has done are frequently recognized 
in elderly people. 

The cause of this morbid condition is not always discoverable, but 
it is evidently a frequent sequel of the exanthemata in children 
and, in a large proportion of cases, is associated with a general 
dryscrasia resembling struma which has been described by Potain 
under the name lymphatism. 

The subject of the condition, when it exists in a marked degree, 
presents a facial expression which is in a measure pathognomonic. 
If a child he goes about with open mouth and a very dull counte- 
nance, the eyes are heavy and stupid, the external nose is rather 
small and undeveloped and the upper lip is thick and prominent. 
Eflacement of the naso-labial furrow and distention of the trans- 
verse nasal vein are often noticeable. The palatal arch is usually 
high, narrow and Y-shaped, and the upper jaw tends to protrude. 
Xasal breathing, through the day, may be natural or impeded, but 
at night respiration is noisy and labored. The child frequently 
awakens from sleep suddenly as though startled by troubled dreams. 
The voice has a peculiar quality called the "dead voice" in which 
there is decided lack of resonance. Hearing is generally impaired 
and the patient has frequent attacks of earache. Xose-bleed is a 
common symptom and, in children, should always excite suspicion 
of the existence of adenoids. A purulent discharge from the 
nostrils, often producing excoriation and eczema of the upper lip, is 
very common. Frequently the patient is disturbed by hacking 
cough, paroxysmal in character, or actual attacks of laryngismus 
may be induced. Asthma, chorea, enuresis and prolapse of the 
rectum' are some of the ills attributed with more or less reason to 
adenoids. Deformity of the chest wall, " pigeon breast," is referred 
by some to labored respiration caused by the clogging up of the 
postnasal space. Probably the thoracic deformity is due quite as 
much to the depraved systemic condition as to the mechanical 
obstruction to breathing. We find many cases occurring in the 
same family, whether attributable to heredity or to the fact that the 
patients are all in a similar environment is not determined. Climatic 
and atmospheric conditions play an important part in the develop- 



ADENOIDS. 207 

ment of the lesion. Dampness, bad air and unsanitary surroundings 
certainly predispose to it. Enlargement is not always due to 
hyperplasia or increased connective tissue but may be a simple 
temporary turgescence; consequently it is not unusual to see extreme 
changes in the dimensions of the adenoid mass. When it has been 
subjected to repeated attacks of acute or subacute inflammation 
more or less permanent thickening results. Lennox Browne sug- 
gests a relationship between adenoid vegetations and laryngeal 
neoplasms in children from the fact that the former are "responsible 
for much infantile laryngitis," a condition doubtless predisposing to 
neoplastic formation. He refers to cases of dyspnea after removal 
of a tracheal canula in diphtheria relieved by ablation of adenoids 
(Martha) in confirmation of his opinion that excision of tonsils and 
adenoids is advisable even in an acute stage of diphtheria as a means 
of averting the necessity of a tracheotomy. The propriety of 
eliminating morbid conditions in the upper air tract in new growths 
of the larynx cannot be questioned, yet the proportion of the latter 
to hypertrophied tonsils and adenoids is so small that an etiological 
connection is very doubtful. In the light of the present improved 
therapeutics of diphtheria the radical disposal of enlarged tonsils in 
the course of that disease as proposed will hardly meet with general 
favor. 

From a pathological standpoint four varieties of adenoid growths 
have been described (Kyle). First, a soft, diffuse, friable mass, 
composed mostly of lymphoid tissue and covered with a thin layer 
of epithelium. Second, an edematous, or cyanotic, form in which 
the gland tissue is but slightly increased, the enlargement resulting 
rather from venous stasis and edema. It is apt to occur in children 
affected by some intestinal irritation or circulatory disturbance. 
Third, a hard variety in which there is decided increase of connective 
tissue as well as of lymphatic elements. Fourth, also a hard form 
caused by repeated attacks of acute or subacute inflammation 
followed by organization of connective tissue and moderate contrac- 
tion. It is usually secondary to intranasal disease. 

For practical purposes a division into soft and hard meets all 
requirements. It is quite probable that many adenoid cases are 
needlessly subjected to operative interference, owing- to lack of ap- 
preciation of the fact that in some children these lymphoid structures 
are very sensitive to external impressions and systemic derangements. 



208 DISEASES OF THE NOSE, THROAT AND EAR. 

They are prone to temporary turgescence or inflammation, when 
many of the subjective symptoms caused by established lymphoid 
hyperplasia or by an acute inflammatory process are exhibited. 
Preparations may be made to operate on a case of this kind and 
when the time comes little or nothing is found to be attacked. 

The symptoms of adenoids vary with the degree of their develop- 
ment and the relative dimensions of the nasopharynx. A moderate 
mass in a contracted pharynx may create grave disturbance, while 
a large volume is carried in a capacious pharynx without much 
complaint. The temperament of the patient also has a bearing on 
the subjective symptoms. In a nervous impressionable child the 
general perturbation is more marked than in one of phlegmatic dis- 
position. As already suggested the symptoms refer primarily to 
the functions of respiration and audition. A very large proportion 
of cases of impaired hearing in adults may be traced to neglected 
adenoids in childhood. A very curious condition of mental lethargy 
denominated aprosexia (Guye), marked chiefly by inability to con- 
centrate the attention, is clearly referable to this condition. Children 
previously stupid and backward frequently gain average intelligence 
after having been relieved of their impediments. The dullness in 
these children is explained in part by impairment of hearing and in 
part by the obstruction to the cerebral lymphatic circulation. An 
interesting example of this condition reported by Jonathan Wright 
occurred in a boy of fifteen who complained that "he could not 
remember or fix his mind on his tasks." Two or three minutes after 
a digital examination, which revealed a considerable collection of 
adenoids, he fell in a slight convulsion lasting less than a minute. 
On recovery he appeared dazed and stupid for some moments and 
was impressed by the belief that he had been given an electric shock. 
This and a similar case are looked upon as instances of nasopharyn- 
geal reflex as well as of aprosexia, the former assumption being less 
well founded than the latter. Care should be taken not to confound 
the shock and faintness attendant upon an examination like that 
made in these cases, and especially apt to occur in children of the 
adenoid class displaying the neurotic disposition, with a true reflex. 
There is an unmistakable impression upon the general health as a 
result of the restlessness at night caused by mouth breathing. The 
obstacle to respiration is aggravated by the increase of blood in the 
parts in a recumbent position and by the muscular relaxation occur- 



ADENOIDS. 209 

ring in sleep. In most cases the faucial tonsils are also hypertro- 
phied and drag the tongue back over the larynx in such a way as to 
still further constrict the air channel. A peculiar change in the 
quality of the voice is almost invariable, but frequently in addition 
there is a faulty enunciation of some of the consonants, or actual 
stuttering results. Frequently the glands at the angle of the jaw or 
in the lower cervical triangle are enlarged. The sense of taste is 
impaired or lost from dry mouth. The act of swallowing is inter- 
fered with, and not infrequently food is regurgitated into the naso- 
pharynx from relaxation of the soft palate. 

The diagnosis is seldom difficult; usually the facial expression is 
characteristic and the condition may be surmised at a glance. 
Attention has been directed to the fact that the so-called " adenoid 
fades" is simulated in certain conditions of nasal obstruction and 
may be quite pronounced when no adenoids whatever are present, 
and on the contrary some cases of extreme lymphoid hyperplasia do 
not exhibit the typical physiognomy. The following are enumerated 
by Chappell among the conditions causing respiratory stenosis 
resembling that due to adenoids. Most of them are peculiar to 
early life and several are so rare as to be unworthy of consideration. 
(1) Lymphatism and lithemia, (2) syphilitic and gonorrheal rhinitis, 
(3) congenital occlusion of the nares, (4) digestive disturbances, (5) 
congenitally high arched palate, (6) small or occluded nostril, (7) 
unusually small postnasal space, (8) anterior projection of the bodies 
of the cervical vertebrae, (9) some malformations of the soft palate, 
(10) hypertrophy of the tongue. Natier insists that in certain neuro- 
tic children a state of " false adenoidism" sometimes exists which is 
corrected by attention to the general health and by the use of 
methodical breathing exercises. It would appear, therefore, that a 
positive opinion cannot be safely based upon suspicious appearances. 
The rhinoscope, or the finger, must be used in every case. In young 
children pharyngoscopic examination is difficult, yet with a little 
patience a satisfactory view is obtained even in unpromising subjects. 
Digital examination gives us infallible testimony. It is not very 
agreeable to the patient but is done with celerity and safety in a way 
elsewhere described (p. 17). The sensation conveyed to the finger 
by a mass of adenoids is unmistakable. It has been likened to that 
of a bunch of "earth worms." The soft form of adenoids is elastic, 
compressible, tabulated and vascular, so that the examining finger 
14 



2IO DISEASES OF THE NOSE, THROAT AND EAR. 

on its withdrawal is stained with blood even though but little force 
has been used. The hard variety is more resistant and smoother as 
well as less vascular. If a rhinoscopic view is possible the arches of 
the choanse are seen to be obscured by pendulous masses hanging 
from the vault and often invading the posterior nares. The view 
obtained in the mirror is very deceptive and should not be relied 
upon in estimating the quantity of adenoid vegetations in a given 
case. An opinion as to treatment must be based upon the history of 
the case and the information gained by exploring with the finger 
(Fig. 85). 

The prognosis is good provided the conoition be recognized early 
and the adenoids thoroughly removed. If allowed to remain with 





Fig. 85. — Adenoids in Vault of Pharynx Seen Through Dilated Anterior Nares. 

(Griinwald.) 

the hope of the occurrence of atrophy, associated derangements, as 
for example in the ears, may progress to an irremediable degree. 
In the hard variety of adenoids there is no use in wasting time over 
local applications or in an endeavor to improve the general condition 
of the patient. The depraved general state is so clearly aggravated 
by, if not the direct result of, the local condition that the latter 
demands first attention. Engorgement of the adenoid mass due 
to inflammatory or intestinal disturbance is relieved by appropriate 
treatment and does not require the radical interference demanded in 
established disease. In the soft variety and in very young children 
when the symptoms have not long existed removal of the mass by 
simply scraping with the index finger frequently suffices. In in- 
fants of two years and under this is readily done without an anesthe- 



ADENOIDS. 211 

tic, attention being paid as far as possible to asepsis by preliminary 
cleansing of the hands of the operator and of the nasopharynx with 
a saturated boric acid solution. In these cases and when an 
anesthetic is used the jaws must be held apart with a mouth gag 
(Fig. 86). 

In older children in whom obstructive symptoms are persistent 
it is a better plan to remove the growths thoroughly under ether or 
other anesthetic. Thus the shock of the operation is less and oppor- 
tunity is given for deliberate and careful exploration and, conse- 
quently, more thorough removal. 




Fig. 86. — Denhard's Mouth-Gag. 

Contrary to the generally received opinion that chloroform is a 
safe anesthetic in children T. H. Halsted maintains with much rea- 
son that the lymphatic diathesis especially favors the depressing 
effect of chloroform upon the heart. This observer prefers ether, 
and to mitigate its suffocative effects and the after nausea he recom- 
mends the instillation into the nares of two or three drops of a 5 
or 10 per cent, solution of cocaine. Many operators rely upon 
chloroform at all ages, in spite of the fact that it is less safe than ether. 
The indiscriminate use of cocaine is unwise, yet it seems to be clearly 
established that reflex respiratory inhibition may be prevented by 
an application of a 2 per cent, solution of cocaine. According to 
George Crile a much weaker solution, even a 0.5 per cent., is 
effectual. It is well known that atropine prevents cardiac inhibition. 
This observer goes so far as to advise in operations in this region a 
preliminary application of cocaine or eucaine and a hypodermic 
of atropine. With the mode of anesthetization presently to be 
recommended the employment of these drugs is entirely unnecessary. 
The statement is made by James Ewing that about fifteen deaths 
from chloroform in lymphoid cases have come to his knowledge 



212 DISEASES OF THE NOSE, THROAT AND EAR. 

and the conviction is growing that chloroform is especially fatal in 
cases of this class. In the face of all the adverse testimony its 
continued use should not be countenanced. 

The number of casualties under general anesthesia has reached so 
large a total, very many cases never having been reported, that we 
are called upon to exercise the utmost care and intelligence in the 
administration of whatever anesthetic may be selected. So far as 
possible all contraindications should be eliminated and the actual 
responsibility of giving it should be entrusted only to an expert. 
The observation and experience of F. W. Hinkel fully corroborate 
the views just expressed and justify the conviction that chloroform 
should never be used in these cases. Its advantages by no means 
outweigh its perils and should not be considered in the presence of 
other anesthetics relatively safe and equally effective. 

Ethyl bromide and ethyl chloride are used more or less, but have 
their dangers. The tendency of the latter to increase the coagu- 
lability of the blood and thus favor the occurrence of pulmonary 
embolism has been pointed out by Mennell. A rather strong case 
is made for the chloride by the report of the London Throat and 
Ear Hospital by Kingsford. In 11,723 administrations there were 
no fatalities and only six occasions when there was reason for serious 
anxiety on account of suspension of breathing. Great care should 
be employed in the manufacture of ethyl bromide. It is possible 
that some of the accidents attending its administration and conse- 
quent prejudice against it may be due to the use of an impure 
product. Eman and De Roaldes, whose experience with it has 
been extensive and favorable, lay stress on this particular. It 
should be given to a patient only in the recumbent position, and 
unconsciousness is induced rapidly by giving 5 to 10 grams of ethyl 
bromide before chloroform or ether. Schmidt mentions the occur- 
rence of death in five cases under ethyl bromide presumably due 
to cardiac weakness. On the other hand, Gleitsmann, who formerly 
preferred the well-known A.C.E. mixture, has used ethyl bromide 
in many hundred cases without an accident. Emil Mayer has had 
excellent satisfaction with the Schleich mixture, of which about 
4 drachms is sufficient to produce complete narcosis in four to six 
minutes, and recovery is equally rapid, but his confidence in this 
combination is not generally shared because of the notoriously 
unequal volatility of its ingredients. 



ADENECTOMY. 213 

It is improbable that general agreement will ever be reached as to 
the kind of anesthetic desirable, or even as to the necessity of any 
anesthetic. It is the custom with many general practitioners to 
scrape the vault of the pharynx of very young children with the 
finger-nail, but this is far from being an aseptic or an effective 
instrument. This method without anesthesia may answer in clinics, 
but will not do in private practice, if we wish to retain the trust and 
good will of our little patients. A vigorous opponent of anesthesia 
appears in H. Gradle, who has designed a special adenotome, 
modified from one proposed by Schuetz (Fig. 87). The size and 
curve of the instrument are such as to fit any pharynx above the 




Fig. 87. — Schuetz's Adenotome. 

fourth year, and in rather a large experience he has found it invari- 
ably capable of removing all the growth with much less .hemorrhage 
than after any other mode of operating. Its action is quick and 
relatively painless, and there is less shock and less risk than with any 
instrument under general anesthesia. The latter this observer 
condemns, except in unmanageable children, or when the faucial 
tonsils are to be removed at the same time. 

The method, of giving ether elaborated by Fillebrown and Rogers 
is sometimes recommended, but is more especially useful in long 
operations in which it is important that the manipulations of the 
surgeon should not be interfered with. In their apparatus ether 
vapor is forced through a tube to the patient's face by means of a 
bellows worked by the foot. 

My own preference is strongly in favor of the use of nitrous oxide 
gas, followed by ether, as being decidedly the safest and most ex- 
peditious mode of procedure. The danger of -anesthesia is thus 
reduced to the lowest possible degree and the operation itself is 
much expedited by preliminary use of nitrous oxide, das alone is 



214 DISEASES OF THE XOSE. THROAT AXD EAR. 

too transient. In very young children the drop method of etheri- 
zation is most satisfactory. 

All danger, of asphyxiation from inspiration of foreign matter 
is obviated by placing the patient in Rose's position with the head 
dependent over the end of the operating table so that blood clots 
and debris accumulate in the pharynx rather than gravitate toward 
the larynx. The upright position in operating was preferred by the 
late F. H. Hooper, who was among the first in this country to realize 
the serious importance of adenoid hypertrophy. His contributions 
to the literature of the subject and his suggestions as to operative 
technic possess a permanent value. His views as to position in 
this as well as in other operations in the upper air tract have some 
advocates at the present day. among them T. R. French, who has 
devised a chair to which the patient is strapped after partial anes- 
thesia in a horizontal position. In order to avoid disturbance of 
circulation and cerebral anemia the patient must be very slowly 
raised to a sitting posture. The advantages claimed are first, 
marked reduction in amount of blood lost, second, lessened chance 
of ear complications owing to thorough drainage of blood from 
the rhinopharynx. third, retention of the usual relationship between 
operator and patient, whereby the operation is much facilitated. In 
certain cases loss of blood may be a matter of some consequence, but 
as a rule hemorrhage in adenectomy is inconsiderable. Great 
stress is laid upon danger to the ears from retention of blood clots 
about the Eustachian orifices, which seems to me more fancied 
than real in the light of my experience with the recumbent position 
without a single case of ear complication. There is some force in 
the statement that operations with the head dependent are more 
awkward and difficult than when it is upright in a position to which 
we are accustomed in everyday work. This would be more generally 
admissible, but for the fact that the operation for adenoids is 
usually done without the aid of the sense of sight. 

In the early periods operative procedures, as practised and recom- 
mended by Meyer, of Copenhagen, whose name has been made illus- 
trious by his invaluable researches of this subject, consisted of 
removal of these growths by the sharp curette, or ring knife, passed 
through the- anterior naris and guided by the finger introduced behind 
the velum Fig. 88). It soon became apparent that they could be 
more easily reached through the mouth and various postnasal for- 



ADENECTOMY. 



2 I 



ceps have been devised for the purpose. Those first used were 
intended for avulsion (Fig. 89) but in attempting to tear the growth 
from its site there is danger of stripping up the mucous membrane 
so that cutting instruments are now preferred (Fig. 90). The 
blades of the forceps in use to-day are much larger than those orig- 



Fig. 88.— Meyer's Ring Knife. 

inally employed with the object of enabling us to do the operation 
more rapidly. It is a good plan to have a variety of forceps and cu- 
rettes, some to cut anteroposteriorly and some laterally (Fig. 91). 
The forefinger or steel finger nail as recommended by Dalby or 
Motais (Fig. 92), with the Gottstein curette (Fig. 94) and the 




Fig. 89. — Loewenberg's Adenoid Forceps. 

large-bladed forceps of the author (Fig. 96) comprise the instru- 
ments capable of meeting all possible contingencies. Many 
operators express strong preference for the cold wire snare to be 
introduced through the nostril or by means of a curved canula 
behind the velum. The use of Ingal's nasal cutting forceps some- 




Fig. 90. — Brandegee's Adenoid Forceps. 



what modified has recently been strongly advocated by Otto Freer, 
(Fig. 93). In rare cases in which the patient refuses to submit to 
the knife or in which we apprehend hemorrhage the galvano- 
cautery may be resorted to, applied under the guidance of the mirror 
behind the velum with the aid of the palate hook, the parts having 



2l6 



DISEASES OF THE NOSE, THROAT AND EAR. 



been thoroughly cocainized. We endeavor in every case to remove 
or destroy the tissue as thoroughly as possible, and after the forceps 




Fig. 91. — Schuetz's Anteroposterior Forceps. 

and curette have been employed the parts should be explored for 
possible remnants or tabs of adenoid tissue still requiring attention. 




Fig. 92. — Motais' Artificial Finger Nail. 

The after-treatment consists simply in keeping the patient at rest. 
It is unwise and unnecessary to disturb him by any application or 




Fig. 93. — Freer's Pernasal Adenoid Forceps. 

douching; the drainage in this region is so perfect that indications 
of septic infection are almost unheard of. Attention has been 



ACCIDENTS IN ADENECTOMY. 



217 



drawn by C. G. Kerley to the occurrence of adhesions after adenec- 
tomy. He maintains that it is frequent and should be obviated 
by passing the finger into the vault of the pharynx at intervals during 
convalescence. A number of cases of hemorrhage and several 
of fatal bleeding after removal of adenoids have been reported by 




Fig. 94. — Gottstein's Adenoid Curette. 

J. E. Newcomb and others, and serve to impress upon us the 
importance of securing the history of all cases before operation as 
well as of careful attention afterward. Children should not 
be permitted to sleep continuously for several hours; they should 
be watched for any irregularity in the circulation. Should there 




Fig. 95. — Beckmann's Curette. 

be signs .of persistent bleeding, after failure of attempt to check 
it by means of astringent irrigations of alum or tannogallic acid, 
the naso-pharynx should be firmly packed with gauze passed 
in through the mouth; or the plugging is accomplished as in epistaxis. 




Fig. 96. — Author's Adenoid Forceps. 

A combination of an alcoholic solution of tannin and antipyrin as 
a hemostatic was hit upon accidentally by Roswell Park, who speaks 
enthusiastically of its efficacy in a case of hemorrhage after removal 
of adenoids by F. W. Hinkel, as well as in bleeding in other situa- 
tions. It forms a gummy adhesive mass which clings closely to 



2l8 DISEASES OF THE NOSE, THROAT AND EAR. 

the part to which it is applied and makes a firm impenetrable tam- 
pon. The difficulty in removing it is the main objection to it, per- 
haps a minor one in general, but which applies to all tampons in 
cases of hemophilia. This point is very strikingly illustrated in 
cases described by A. A. Bliss. One of these, a case of deviated 
septum and adenoids, resulted fatally on the fourth day, recurrence 
of bleeding taking place on the slightest attempt to disturb the tam- 
pon. The obvious lesson is that all operative cases should be care- 
fully investigated beforehand for the possible existence of hemor- 
rhagic diathesis. It is a strange fact that some of the victims of 
hemophilia underestimate, or exhibit a moral perversity which leads 
them to conceal, their weakness, and our first intimation of its exis- 
tence may be the occurrence of bleeding after operation. It is prob- 
able that in the product of the suprarenal gland we have an antidote 
to this condition more reliable than any hitherto possessed, but the 
fact remains that cutting operations in bleeders are better avoided. 
The administration of calcium chloride or lactate as a prophylactic 
as well as for the control of hemorrhage is of apparent value. 

In the use of cutting instruments in the post-nasal space certain 
accidents may occur which may be obviated by the exercise of ordi- 
nary care. First, the margin of the velum may be lacerated by the 
blade of the forceps unless the instrument be passed well into the 
vault of the pharynx before being opened, the palate meanwhile 
being dragged forward by means of the left forefinger hooked behind 
it. Second, the edge of the vomer may be nicked if the handle of 
the forceps be too much depressed, not a serious matter but as well 
omitted. Third, the Eustachian cushion may be bruised or cut by 
carelessly tilting the instrument too much to one or the other side. 
Finally, a considerable flap of mucous membrane may be stripped 
from the posterior wall of the pharynx, which may be prevented by 
ploughing up the lymphoid tissue from below with the finger nail 
before applying the forceps, or by pressure with the finger tip at 
the lower limit of the adenoid mass while it is being torn from its 
attachments. While these incidents are usually of minor importance, 
on the other hand they may become somewhat embarrassing com- 
plications and prolong convalescence. 

Inflammation of the middle ear is an occasional sequel of adenec- 
tomy and is most liable to occur in those who have already suffered 
from aural complications. Children who have had otorrhea, or 



ADENOIDS. 219 

been subject to earache, should receive special attention as regards 
precaution against exposure after operation. A curious phe- 
nomenon has been observed in several cases after removal of lym- 
phoid hyperplasia, referable to excessive energy in the use of the 
curette or forceps, or to some peculiar neurotic state of the patient, 
namely torticollis, a complication developing two or three days after 
operation and subsiding in the course of a week as the wound 
gradually heals. 

The question is often asked as to the probability of relief of 
symptoms and of recurrence after removal of adenoids. In a 
large proportion of cases the relief is immediate and marked. 
Patients who have previously disturbed the household by noisy 
breathing at night will sleep so tranquilly as to excite the alarm of 
anxious parents. In certain individuals, however, in whom the 
habit of mouth breathing is firmly established and in whom, also, 
the parts are ill developed from prolonged disuse, nasal respiration is 
not immediately free. Under these circumstances we are sometimes 
obliged to resort to measures for closing the mouth during sleep and 
aiding the patient to learn the use of the nose for breathing. A 
shield worn within the lips or simply binding up the chin generally 
answers the purpose. Recurrence of adenoids may take place, even 
after thorough removal, especially when the operation has been 
performed early in life, in children of pronounced lymphatic ten- 
dencies. In many, however, it must be admitted that relapse is due 
to incompleteness of the operation, or to a coexistent obstruction 
within the nasal cavities. The last mentioned factor is of the ut- 
most importance and in all cases of adenoids at any period of life 
nasal stenosis which is always productive of a state of hyperemia and 
favors the reformation of lymphoid tissue should be remedied. 

In older children and adults general anesthesia is not requisite. 
With cocaine and a large curette the operation may be done at one 
sitting. Most patients consider this preferable to frequent repeti- 
tions of a performance always uncomfortable and often painful. In 
manageable subjects the forceps is used with the aid of a palate 
hook and under the guidance of the mirror. This is the most 
satisfactory and precise mode of operating, but is seldom found to bo 
applicable, and we are compelled to rely upon the tactile sense in 
determining the character and distribution of the vegetations. The 
fossae of Rosenmuller as regards the ears, and thechoanae, as regards 



2 20 DISEASES OF THE NOSE, THROAT AND EAR. 

breathing, are critical situations and are most effectively and safely 
reached with the forefinger, or, in case the operative field can be seen, 
with a small curette. Xeglect of the latter region is a prominent 
cause of failure in the operation. Masses of lymphoid tissue may be 
crowded into the nares by the forceps or curette, or may be actually 
attached at some point anterior to the choanae. Hence the sugges- 
tion of Ingals to clear out the posterior nares by means of nasal 
cutting forceps passed from the front is valuable. Or a small ring 
knife may be of service in this situation. In any case to give the 
best results the operation must be thorough, every vestige of morbid 
tissue being sought for and removed. Xo doubt it is possible for 
anyone to pass a curette into the nasopharynx and scrape away more 
or less tissue, but this is not adenectomy as it should be done and 
tends rather to bring the operation into disrepute owing to incomplete 
relief and recurrence of symptoms. Properly done there is no pro- 
cedure in the domain of rhinology mare prompt and satisfactory in 
its effects. 



CHAPTER XIII. 

HYPERTROPHIED TONSILS. 

Hypertrophied tonsils appear in two forms: the hard or fibrous 
tonsil which results from repeated attacks of acute, or subacute, 
amygdalitis, and the soft, or adenoid, which is the more frequent 
variety and occurs earlier in life. The former is apt to be accom- 
panied by more or less chronic pharyngitis, and to persist after 
puberty, marked examples having been observed in advanced life. 
The second variety of hypertrophied tonsil is almost always asso- 
ciated with lymphoid hyperplasia in the nasopharynx, as well as at 
the base of the tongue. In other words, the hypertrophy includes what 
has been called "the lymphoid triangle," or "ring of Waldeyer." 
The mucous membrane of the follicles, rather than the parenchyma 
of the tonsil, is affected. The tonsils may be excessively enlarged 
only when acutely inflamed. They atrophy earlier and more com- 
pletely than the hard variety, but frequently the former merge by 
slow gradations into the latter in consequence of repeated attacks of 
inflammation resulting in the formation of new connective tissue. 
The hard tonsil is hyperplastic, the stroma of the gland being devel- 
oped by the growth and proliferation of connective tissue. The 
second form of enlarged tonsil is a genuine hypertrophy, the glandu- 
lar tissue being mainly involved. 

From a clinical standpoint with special reference to treatment we 
may divide enlarged tonsils into three varieties: first, those whose 
size interferes with deglutition or respiration; second, flat tonsils not 
especially enlarged but prone to recurrent attacks of inflammation 
and frequently the foci of suppurative inflammation, the formation 
of pus taking place not necessarily in the body of the tonsil, but in 
the adjacent tissue; third, a class of tonsils in which there is little 
or no apparent hypertrophy or encroachment upon the pharyn- 
geal space because of adhesions of the pillars to the surface of the 
organ as a result of repeated attacks of inflammation. Thus the 
tonsil, in the process of hypertrophy, carries with it the palato- 
glossal fold which is spread over its surface as a thin veil; or the 

221 



222 DISEASES OF THE NOSE, THROAT AND EAR. 

anterior pillar may be considerably thickened. In either case 
adhesions should be released if possible before attempts at reduction 
or removal of the gland are undertaken. Considerable shrinkage 
of the tonsil is observed to take place after this procedure. 

The degree of enlargement varies greatly in 'different cases. 
There may be hardly perceptible swelling, although the crypts are 
in a state of chronic disease, or the tumefaction may be so extreme 
as to bring the tonsils almost in contact. Usually the hypertrophy 
is more or less symmetrical; in rare instances one tonsil is large, the 
other being nearly normal. The latter condition gives reason to 
suspect the existence of syphilis, or the development of a neoplasm. 
When the formation of connective tissue is a marked feature the 
surface of the tonsil is smooth, the crypts being, to a greater or less 
degree, obliterated. The tonsil looks dense, hard, and fibrous. 
The true hypertrophied tonsil, in which the lacunae are chiefly 
involved, is irregular in contour and even lobulated. 

The symptoms caused by hypertrophied tonsils are variable. 
There is no pain except when they are inflamed, but there- may be 
discomfort and a sensation like that caused by a foreign body, with 
desire to swallow and, at times, some dysphagia with tendency to 
regurgitation of fluids through the nose. Usually the development 
is very gradual and the surrounding parts become accustomed 
to their presence. Reflex vomiting has been reported in some 
cases, and gastric disturbance is mentioned by many observers, either 
as a reflex neurosis, or from irritation of the alimentary canal by 
perverted secretions. Earache, impaired hearing and tinnitus 
auriuni are referable to the condition, but are more likely to depend 
upon an associated lymphoid hypertrophy in the vault of the 
pharynx. The latter condition, also, is usually responsible for 
mouth breathing and the heavy, stupid facial expression seen in 
children the victims of this anomaly. Reflex asthma and paroxys- 
mal cough have been cured by ablation of these bodies. Enlarge- 
ment of the tonsil is probably never congenital, although it has been 
met with at a very early period of life, and it is not unusual to 
find examples of it in several members of the same family. Those 
affected may be inclined to a strumous diathesis, or have a feeble 
constitution. But, on the other hand, we not infrequently meet with 
this condition in those who present no evidence of scrofulous taint 
or malnutrition. It rarely makes its appearance after maturity and, 



HYPERTROPHIED TONSILS. 223 

in many cases, we secure a history of previous attacks of acute in- 
flammation. It is a curious fact that, in some cases in which re- 
peated attacks of tonsillitis occur, there is no decided increase in the 
size of the tonsils; while, on the other hand, we now and then see 
extreme hypertrophy without special tendency to acute inflamma- 
tion. The damage caused by enlarged tonsils includes not only 
the immediate neighborhood of the pharynx but the general health. 
They also play an important part in the matter of infection and 
are a serious complication in the event of contagion. They are 
a source of constitutional disease by the mechanical impediment 
they offer to respiration and by vitiation of the inspired air result- 
ing from decomposing secretions incarcerated in their diseased 
lacunae. In addition various reflex disturbances are referred to 
them. Yet, in spite of the mass of evidence against them, we 
still hear the advice given to allow the patient to outgrow the condi- 
tion. There is no valid excuse for such advice. While a child 
is outgrowing tire -enlargement he is exposed to all the dangers 
that have been recounted, whereas, under modern methods of oper- 
ating, the risks of surgical interference have been reduced to a mini- 
mum. The danger attending their removal is far less than that 
involved in the retention of diseased or hypertrophied tonsils in the 
pharyngeal cavity. The improvement in general health and in the 
local conditions, which almost invariably follows removal of the 
offending bodies, is sufficient argument in favor of the operation. 
Treatment. — The constitutional treatment of enlarged tonsils 
is seldom satisfactory. The best of hygiene, and diet, and the 
use of the most powerful tonics are not capable of eradicating the 
fibrous tonsil. Nevertheless, anything which tends to improve the 
general health should be employed as an adjunct to local treatment. 
In some instances, a soft tonsil is reduced to some extent by the 
use of astringent applications, or interstitial injections of iodine 
or corrosive acids. Massage of the tonsil has been recommended 
by many and seems to have been used with success in some 
cases. The process of absorption is assisted by compression of 
the tonsil, and electrolysis has been resorted to for a similar 
purpose. But these methods are all tedious and are just i lia- 
ble only in case of contraindication of more radical surgical 
measures. As to the latter it becomes necessary to determine the 
method of operating best adapted to a given case, as well as the 



224 DISEASES OF THE NOSE, THROAT AND EAR. 

best time for operating. The suggestion is sometimes made that 
it is better to postpone interference until improvement in the general 
condition has been secured. I have never seen reason to consider 
interference premature even in children who appeared to be in 
extremely poor general condition. It is not wise to operate upon 
a tonsil when it is acutely inflamed, although it has often been 
done and is still advised by some. The pain, the subsequent 
reaction, and the hemorrhage are apt to be unusual under these 
circumstances; nevertheless, we should not hesitate to interfere in 
case of threatened asphyxia from extraordinary swelling. It is 
injudicious to operate during the prevalence of an epidemic of scarlet 
fever or diphtheria, and indeed some go so far as to interdict the 
operation in a general hospital. In view of the startling frequency 
with which the Klebs-Loefrler bacillus, not to mention other septic 
organisms, has been found on the surface of a tonsillotomy wound 
such advice may not seem misplaced. The mode of operating 
depends upon the shape, the size and the relations of the tonsil. 
The best instrument when the tonsils are prominent is the amygdalo- 
tome; but, in certain cases, owing to the peculiar shape of the organ 
we must resort to other methods. Again fear of hemorrhage, which 
is justified in some cases, compels us to select a bloodless substitute for 
the knife. Various chemical caustics have been tried with more or 
less success. Nitrate of silver, fused on a probe and passed into the 
crypts, chromic acid applied in a similar way or inserted into the body 
of the tonsil through small incisions and London paste applied to the 
surface of the tonsil with a spatula, have given some degree of satisfac- 
tion. These agents have to be reapplied at intervals according to the 
amount of execution they do and the degree of reaction that follows 
them. The Paquelin cautery and the galvano-cautery are much 
more energetic and precise, and in proportion to their greater effect- 
iveness they are more painful and are followed by more intense 
reaction. In a trained, tolerant patient, after application and 
interstitial injections of cocaine, the whole tonsil may be destroyed 
with the electric cautery at a single sitting (Cullen) ; but, with a view 
to the patient's subsequent comfort, it is well to be satisfied with 
partial destruction of the gland at one time, accomplishing its 
complete removal in numerous sittings. Galvano-cautery puncture 
is adapted to flat embedded tonsils, the removal of which with the 
knife or guillotine is difficult or impossible. It is a good plan to 



HYPERTROPHIED TONSILS. 



22^ 



cauterize three or four adjacent crypts in succession, the cold 
electrode being passed to the bottom of the crypt and brought out 
hot to the surface of the tonsil. In this way large segments of 
tonsillar tissue are destroyed and there is little or no danger of 
retention of sloughing tissue which may become a focus of suppura- 
tion. The electro-cautery 
method of dealing with enlarged 
tonsils is objected to on the 
ground that it leaves a large 
uneven surface and a sensitive 
cicatrix, but if it is used with 
discrimination there is no reason 
why the stump should not be 
perfectly smooth and insensitive. 
Enucleation of the tonsil by 
means of the finger, a method 
used and abandoned long ago, 
promises to be revived, especially 
by those who favor removal of 
every vestige of the tonsillar 
mass. It is sometimes easy to 
strip up the tonsil, together with 
its capsule, in its upper, portion, 
but adhesion becomes more firm 
as we approach the lower part, 
where the nutrient artery enters. 
For this reason, as well as a pre- 
caution against hemorrhage, par- 
ticularly in adults, it is good 
practice to snare off the lower 
half with the cold wire loop. 
Or the entire operation is effec- 
tively done with the wire snare, 
the tonsil being drawn into the 
loop by a properly constructed forceps (Fig. 97). In adults with 
prominent tonsils somewhat constricted at their base and in 
children under general anesthesia the latter is a most excellent way 
of operating. 

The hot-wire snare offers advantages over the cold-wire in com- 




224 DISEASES OF THE NOSE, THROAT AND EAR. 

best time for operating. The suggestion is sometimes made that 
it is better to postpone interference until improvement in the general 
condition has been secured. I have never seen reason to consider 
interference premature even in children who appeared to be in 
extremely poor general condition. It is not wise to operate upon 
a tonsil when it is acutely inflamed, although it has often been 
done and is still advised by some. The pain, the subsequent 
reaction, and the hemorrhage are apt to be unusual under these 
circumstances; nevertheless, we should not hesitate to interfere in 
case of threatened asphyxia from extraordinary swelling. It is 
injudicious to operate during the prevalence of an epidemic of scarlet 
fever or diphtheria, and indeed some go so far as to interdict the 
operation in a general hospital. In view of the startling frequency 
with which the Klebs-Loeffler bacillus, not to mention other septic 
organisms, has been found on the surface of a tonsillotomy wound 
such advice may not seem misplaced. The mode of operating 
depends upon the shape, the size and the relations of the tonsil. 
The best instrument when the tonsils are prominent is the amygdalo- 
tome; but, in certain cases, owing to the peculiar shape of the organ 
we must resort to other methods. Again fear of hemorrhage, which 
is justified in some cases, compels us to select a bloodless substitute for 
the knife. Various chemical caustics have been tried with more or 
less success. Nitrate of silver, fused on a probe and passed into the 
crypts, chromic acid applied in a similar way or inserted into the body 
of the tonsil through small incisions and London paste applied to the 
surface of the tonsil with a spatula, have given some degree of satisfac- 
tion. These agents have to be reapplied at intervals according to the 
amount of execution they do and the degree of reaction that follows 
them. The Paquelin cautery and the galvano-cautery are much 
more energetic and precise, and in proportion to their greater effect- 
iveness they are more painful and are followed by more intense 
reaction. In a trained, tolerant patient, after application and 
interstitial injections of cocaine, the whole tonsil may be destroyed 
with the electric cautery at a single sitting (Cullen) ; but, with a view 
to the patient's subsequent comfort, it is well to be satisfied with 
partial destruction of the gland at one time, accomplishing its 
complete removal in numerous sittings. Galvano-cautery puncture 
is adapted to flat embedded tonsils, the removal of which with the 
knife or guillotine is difficult or impossible. It is a good plan to 



HYPERTROPHIED TONSILS. 



225 



cauterize three or four adjacent crypts in succession, the cold 
electrode being passed to the bottom of the crypt and brought out 
hot to the surface of the tonsil. In this way large segments of 
tonsillar tissue are destroyed and there is little or no danger of 
retention of sloughing tissue which may become a focus of suppura- 
tion. The electro-cautery 
method of dealing with enlarged 
tonsils is objected to on the 
ground that it leaves a large 
uneven surface and a sensitive 
cicatrix, but if it is used with 
discrimination there is no reason 
why the stump should not be 
perfectly smooth and insensitive. 
Enucleation of the tonsil by 
means of the finger, a method 
used and abandoned long ago, 
promises to be revived, especially 
by those who favor removal of 
every vestige of the tonsillar 
mass. It is sometimes easy to 
strip up the tonsil, together with 
its capsule, in its upper, portion, 
but adhesion becomes more firm 
as we approach the lower part, 
where the nutrient artery enters. 
For this reason, as well as a pre- 
caution against hemorrhage, par- 
ticularly in adults, it is good 
practice to snare off the lower 
half with the cold wire loop. 
Or the entire operation is effec- 
tively done with the wire snare, 
the tonsil being drawn into the 
loop by a properly constructed forceps (Fig. 97). In adults with 
prominent tonsils somewhat constricted at their base and in 
children under general anesthesia the latter is a most excellent way 
of operating. 

The hot-wire snare offers advantages over the cold-wire in com- 





226 DISEASES OF THE NOSE, THROAT AND EAR. 

pleting the section more easily and rapidly and in providing greater 
security against hemorrhage. We meet here also with difficulty in 
engaging the tonsil in the wire loop which the author has endeavored 
to overcome by constructing a loop-adjuster or electric tonsil- 
snare. It is an adaptation of an idea proposed by Toison for the 
cold-wire ecraseur and consists of a double canula carrying the 
wire and attached to a solid steel shaft from which it is insulated 
(Fig. 98). The shaft ends in a ring whose vertical diameter is 
longer to correspond with that of most tonsils. In using the instru- 
ment the wire loop is shaped to adapt itself to the ring (not as 
shown in the cut) to which it is fastened by a fine thread. The 
ring having been carried over the tonsil with the loop toward the 
median line, traction is made so as to bring the wire in contact with 
the tonsil above and below; at this instant, the current being turned 




Author's Electric Tonsil-snare. 



on, the wire burns through the thread which holds it to the ring. 
The loop buries itself in the tonsil and is no longer in danger of 
slipping. The advantages of this instrument are that the loop can 
be carried well over the base of the tonsil and the pillars and tongue 
are held away by the ring and protected from the heat of the cur- 
rent. In using electricity it is to be always remembered that the 
heat must be allowed to do the work and should not be excessive. 
Traction is made upon the wire only when it is cool. Thus traction 
and burning are made in alternation. 

The total result of the operation is not limited to the tissues actu- 
ally removed, the parts left behind being cauterized to a considerable 
depth. The pain of the operation itself may be almost completely 
abolished by parenchymatous injections of cocaine, or alypin. 
The latter is much less poisonous than cocaine, and its analgesia 
is equally prompt and prolonged. It may be kept sterile, or may 
be made so by boiling without damage, and there is no possibility 
of septic infection from its use hypodermically. 

Obviously the electro-cautery loop method of treating enlarged 
tonsils is adapted only to adults, to children under general anesthesia, 



HYPERTROPHIED TONSILS. 227 

and to protuberant tonsils. It cannot be used with flat deep- 
seated tonsils. The reaction is always considerable but may be con- 
trolled in a measure on general principles. It is a good plan to 
remove at one sitting but one tonsil, the second being attacked at the 
expiration of a week or ten days. 

There are four conditions which justify the use of the electric 
cautery as a substitute for a cutting operation: (i) Hemophilia; 
(2) vascular anomalies; (3) peculiarity in the shape of the tonsil, 
and (4) refusal on the part of the patient to submit to the knife. 

A patient known to be a bleeder should never be cut. 

Among vascular anomalies, a misplaced ascending pharyngeal 
artery or a large vessel in the margin of the anterior pillar, may be 
wounded by the knife. Injury to the plexus of veins at the lower 
border of the tonsil may give rise to hemorrhage; and an abnormally 
large tonsillar artery frequently bleeds freely. It is impossible to tell 
from the appearance of the tonsil whether hemorrhage is to be 
expected; a vascular looking tonsil often bleeds but little. In my 
experience this accident has occurred usually in adults with the 
hard fibrous tonsil in which the section has been made near the 
middle of the gland where the blood-vessels do not readily retract in 
consequence of a preponderance of new connective tissue. In the 
opinion of A. A. Bliss the tonsillar artery itself is seldom cut, unless 
the excision be very complete, which he concludes is rarely if ever 
necessary. This view is also held by Damianos, who in reporting a 
fatal case in a hemophile states that about 150 cases of severe bleed- 
ing after tonsillotomy are on record, seven of which were fatal. His 
objection to complete removal seems to be based on the idea that the 
tonsillar artery is so embedded in the inelastic fibrous capsule of the 
gland that its severed end is prevented from contracting. 

Anatomical peculiarities comprise the flat or embedded tonsil, the 
so-called "submerged" tonsil, which cannot be included in the ring 
of the guillotine and with which the use of the knife or scissors is 
tedious and possibly dangerous. Adhesion of the anterior pillar, 
in this situation described by Harrison Allen as the "opercular fold," 
and the advisability of its detachment have been already referred to. 
For this purpose it is well to avoid a sharp and especially a pointed 
instrument. Adhesions are usually easily separated with a right- 
angled, blunt, and somewhat dull-edged knife. Several cases of 
violent bleeding have followed section of this fold. Vet it the 



2 28 DISEASES OP THE XOSE. THROAT AND EAR. 

pillar is very thin, evidently consisting only of mucous membrane, 
and encloses no blood-vessel of importance, its existence may be 
disregarded and the blade of a tonsillotome be carried directly 
through it. provided the tonsil protrudes sufficiently to allow the ring 
of the guillotine to surround it. 

Although called a bloodless method of operating., burning is not 
absolutely free from the risk of bleeding. A number of cases are 
on record in which alarming hemorrhage has taken place on the 
fourth or fifth day from violent detachment of the eschar, as a result 
of excitement in laughing, or crying, or of laceration by a morsel of 
hard food. Ordinary caution in these particulars should ensure 
protection against the accident. The operation itself is rendered 
comparatively painless by local anesthesia, yet there is doubtless 
more reaction after burning than cutting. The fauces should be 
first thoroughly cleansed with an antiseptic spray and the surface of 
the tonsil swabbed with a 10 per cent, cocaine solution. Then with 
an ordinary hypodermic syringe six or eight minims of a 2 per 
cent, solution of alypin are injected into the upper and an equal 
quantity into the lower part of the tonsil. In about three minutes 
anesthesia will be quite complete. 

In a large majority of cases the operation of choice is one of the 
various cutting methods. Most tonsils can be removed with the 
knife more quickly and thoroughly than in any other way. and the 
resulting wound is less irritable and heals more kindly than one left 
by a caustic. The accepted instrument for use in cutting operations 
is a modification of Physick's tonsillotome, proposed several years 
ago by Morell Mackenzie Fig. 99). Many so-called improvements 
have been suggested which complicate the instrument and add to the 
difficulty of the operation. Mackenzie"s amygdalotome recom- 
mends itself for its strength,, its simplicity, its safety and its effi- 
ciency. Rightly used in suitable cases it is capable of ablating 
almost the entire tonsil and that without endangering the large 
blood-vessels in the cervical region. In certain cases a forked 
guillotine, like that of Mathieu .Fig. 100), is serviceable. Spear 
or fork attachments have been known to catch in the ring and 
in several instances a guillotine has thus been broken, either as a 
result of faulty construction or awkward manipulation. Some 
operators prefer a stout bistoury or scissors, but their use is far 
from easy in a field obscured by blood and constantly shifting with 



HYPERTROPHIED TONSILS. 



229 



muscular contractions. It is sometimes difficult to remove the mor- 
bid tissue thoroughly and tonsil punches in a variety of shapes have 
been devised for the purpose of reaching the bottom of the tonsillar 
fossa and the socalled "velar lobe" at the upper border of the 




Fig. 99. — Mackenzie's Tonsillotome. 

tonsil. In order to protect the patient against recurrence of cir- 
cumtonsillar phlegmon it is quite important to remove these deep- 
seated masses. For this reason and because tonsillar remnants 
sometimes become inflamed or hypertrophied, or even harbor 
tubercle bacilli, Freer urges complete excision by dissecting with 




Fig. 100. — Mathieu's Tonsillotome. 

the knife and decries every other method. Morcellement, or 
ablation of the tonsil by crushing with powerful flat-bladed 
forceps followed by excision of the crushed portion, called by 
Ruault "amygdalothripsis," is said to be a satisfactory way of 
disposing of these hypertrophies. The tonsil punch is adapted 



232 DISEASES OF THE NOSE, THROAT AND EAR. 

side after a few minutes it is time to consider measures for its arrest. 
In most cases the application of cold externally and holding bits of 
ice in the mouth will suffice. If these fail, a mixture of tanno-gallic 
acid — one part of gallic and three parts of tannic, in the proportion 
of about twenty grains to the ounce of water — is used as a gargle; 
and small quantities of the solution may be swallowed; the act of 
swallowing driving the styptic into the stump of the tonsil. Paren- 




Fig. 102. — Butts' Tonsillar Hemostat. 

chymatous hemorrhage is almost invariably checked by this pro- 
cedure. Hemorrhage from a large tonsillar artery cannot be thus con- 
trolled and we then shall be obliged to resort to some other method. 
Direct pressure by the finger, or by means of one of the various 
tonsillar hemostats (Fig. 102,) should be tried without wasting time 
over styptics (Fig. 103). Ligation of the tonsil after transfixing the 
stump with a tenaculum is sometimes feasible; but it is not easy to 




Fig. 103. — Mikulicz-Stoerk Tonsil Hemostat. 

ligate a tonsillar artery from which brisk hemorrhage is taking place 
in a nervous frightened child, or even in an adult. The electric 
cautery, or Paquelin cautery will check persistent oozing but will 
rarely control an arterial jet. An ingenious proposition by Levis 
succeeded in an obstinate case under his care; the stump of the 
tonsil was transfixed by a tenaculum; it was then twisted to bring 
the flat handle between the teeth and the jaws were bandaged 



HYPERTROPHIED TONSILS. 233 

together; on withdrawing the instrument next day there was no 
return of hemorrhage. When hemorrhage is to be apprehended 
from any source Seifert advises the use of the galvanocautery snare 
in operating and suggests that one be content to remove not more 
than three-fourths of the tonsil, the latter precaution, however, ap- 
pearing somewhat superfluous in addition to the former. 

Ligation of the carotid artery for tonsillar hemorrhage has several 
times been done, but in at least one such case it seems clear that the 
bleeding was on the point of ceasing spontaneously. On anatomical 
grounds the external carotid, between its superior laryngeal and 
ascending pharyngeal branches, is the vessel indicated for liga- 
tion, but in view of the fact that the importance of this accident 
has been vastly overdrawn a less formidable procedure would seem 
to be preferable. If a stump of tonsil has been left the loop of a cold- 
wire snare may be passed over its base and gradually tightened, or if 
the excision has been complete the tissues may be transfixed with a 
needle in a long handle and the wire slipped over its ends. A very 
ingenious device by Dawbarn consists in surrounding the bleeding 
area with a submucous ligature, or " purse string" ligature, passed 
in four directions. A double-curved needle in a holder and loaded 
with a stout ligature of silk or catgut is passed from before backward 
beneath the bleeding point, then vertically upward behind it, then 
directly' forward and finally downward to the spot where the needle 
first entered. The pillars need not be included by the ligature which 
is practically buried at all points and is allowed to slough out or is 
removed after two or three days. In several cases bleeding has been 
checked by suturing the pillars firmly together. In most cases a ton- 
sillar hemorrhage, if allowed to take care of itself, ceases spontaneously 
on the supervention of faintness with decreased blood pressure, and 
the last remedy used gets the credit of having checked the bleeding. 
This is not an agreeable mode of controlling a hemorrhage, but the 
episode is robbed of , most of its terrors when the patient can be as- 
sured that nature's way of stopping a leak in a blood-vessel is usually 
effective. The results of careful study of this subject made by 
Lefferts have been amply confirmed by others. His conclusions 
were (i) that a fatal hemorrhage after the operation of tonsillotomy 
is very rare; (2) a dangerous hemorrhage may occasionally occur; 
(3) a serious one, serious as regards both possible immediate and 
remote results, is not very unusual; and (4) a moderate one, requiring 



234 DISEASES OF THE NOSE, THROAT AND EAR. 

direct pressure or strong astringents to check it, is commonly met 
with. My own experience with alarming hemorrhage is limited to 
five cases, two in adults and three in children under ten years of 
age. In all the guillotine was used. In two of the children the 
bleeding ceased spontaneously after the failure of several domestic 
measures and when exsanguination had become extreme. In one a 
tonsil hemostat had to be applied and was worn all night. In one 
of the adults direct pressure seemed to be of some service, while in 
the other efforts to stop the flow by torsion and electric cautery were 
unsuccessful, the bleeding ceasing on the occurrence of fainting. 

The use of general anesthesia in removing tonsils has been the 
subject of much discussion. The pain of cutting or burning may 
be mitigated in some degree by the application of cocaine, or the 
parenchymatous injection of cocaine or alypin. It has been sug- 
gested that cocaine increases the liability to secondary hemorrhage. 
General anesthesia seems to me. by all means, more humane, 
especially in young children. The argument against it that 
it deprives us of the assistance of the patient in preventing 
the admission of blood to the air passages, is not valid if the 
anesthesia be not profound. Cases of fatal asphyxia are on record 
from the entrance of blood into the larynx during tonsillotomy 
under chloroform. Some maintain that anesthetization excites 
as much resistance as attempts to excise the tonsil without it. 
My own position is that if given in a proper way. in suitable 
quantities, ether is on the whole the most satisfactory and cer- 
tainly the safest anesthetic. If preceded by nitrous oxide gas, a 
very moderate quantity is required, the suffocative effects of ether 
are obviated, the reflexes are not abolished, and the unpleasant 
after effects are much reduced. By giving a general anesthetic 
in this way we incur no greater risk, we save the patient much 
nervous shock, we permit ourselves better opportunity to examine 
the case carefully and especially to explore the naso-pharynx, 
always a most important thing to do, and if any morbid con- 
dition is found there it may be relieved at the same time. It is 
best to remove the faucial tonsils first in succession, the mouth 
being held open by a mouth-gag; the patient is then turned upon 
the side or the face to permit the blood to drain from the mouth, 
and, after the hemorrhage has subsided, he is replaced upon the 
back and a rapid exploration made of the vault of the pharynx with 



HYPERTROPHIED TONSILS. 



2 35 



the forefinger. It may be necessary to give a little more ether when 
this additional step is taken. 

It seems to be a fact that the danger of hemorrhage has been 
much exaggerated. The number of cases of excessive bleeding 
on record in proportion to the number of tonsils removed is ex- 
tremely small. Nevertheless, especially in adults, the possibility 
of its occurrence should be borne in mind, and before the operation 
is undertaken the patient should be thoroughly informed and, if 
an adult, should be, in a measure, allowed to select the mode of 
operation. 

The question of the advisability of removing enlarged tonsils 
is no longer open. Their injurious effects are so obvious, the 




Fig. 104. — Robertson's Tonsil Scissors. 

benefit following their removal is so apparent and the risks of 
the operation are so slight, that there should be no hesitancy in 
advising it when the necessity arises. We should endeavor to re- 
move as much of the morbid tissue as possible, in other words to do 
a " tonsillectomy," and in order to accomplish this it is necessary 
to resect deep-seated masses with scissors (Fig. 104), knife (Fig. 105), 
or tonsil punch, as a supplement to the use of the guillotine. 
It is not sufficient to make a superficial section for the reason that 
a remnant of tonsillar tissue containing diseased follicles is very 
prone to become the subject of an acute inflammatory process under 
circumstances which excited its occurrence before operation. 



236 



DISEASES OF THE NOSE, THROAT AND EAR. 



It rarely happens that the faucial tonsil reproduces itself after 
radical excision. In very young subjects with a tendency to lymph- 
oid hypertrophy there may be a slight inclination to recurrence. 
But, as a rule, the improved general condition following a nearly 
complete extirpation results in progressive shrinkage of what 
small stump is left. On the other hand, in certain cases a moderate 
growth of lymphoid remnants may take place precisely as in the 
case of adenoids in the pharyngeal vault. Yet the experience 
of Coakley, who states that he did amygdalotomy four consec- 
utive times within as many years on the same patient, is most 
extraordinary. 




Three questions are almost invariably asked whenever a tonsil- 
lotomy is proposed; whether there is any risk from hemorrhage or 
other sources, second, if the tonsils are likely to grow again, and 
finally what effect if any their removal may have upon the voice 
or other function. The first two have perhaps been sufficiently 
discussed. A fear of sexual impairment sometimes suggested is 
based upon a process of reasoning similar to that which discovers 
in suicidal mania a direct result of excision of the tonsils because 
two or three individuals are reputed to have taken their own lives 
shortly after having been cut. The question of damage to the voice 
deserves to be treated more seriously and is more important espe- 
cially in those whose livelihood or enjoyment of life is involved. 
At intervals this objection finds expression in medical literature. 
Personally I have never experienced a case which gave it a shadow 
of foundation. At first there is almost always a startling change 
in the quality of the voice which may disturb the patient and distress 
his friends, but this passes away in a few weeks at most, and is 
succeeded by marked improvement in fullness and resonance as 



HYPERTROPHIED TONSILS. 237 

he learns to modulate his voice and adapt his palatal muscles to 
their new relations. 

A curious post-operative phenomenon, at times possibly leading 
to confusion and even alarm, merits passing notice, namely, "tonsil- 
lotomy rash." It is extremely rare, having been mentioned only by 
Lennox Browne and one or two other writers, but has recently been 
described anew by Wyatt Wingrave and E. A. Forsythe. It occurs 
as a papular, roseolar or erythematous eruption, usually begin- 
ning on the neck, chest and abdomen and thence extending some- 
times to the extremities. It may be attended by considerable itch- 
ing, but disappears in two or three days without desquamation and 
with little or no constitutional disturbance. Its occasional occur- 
rence should be kept in mind with a view to escaping a possible 
disquieting error in diagnosis. 

In conclusion no good reason can be offered for allowing the ton- 
sils to remain when they are clearly proved to be causes of local as 
well as systemic derangement, and no method of removal other than 
surgical is worth considering, except in those very rare conditions 
which have been enumerated. 



CHAPTER XIV. 

DISEASES OP THE LINGUAL TONSIL. ABSCESS OF THE TONGUE. 
RETROPHARYNGEAL ABSCESS. MYCOSIS OF THE PHARYNX. 

HYPERTROPHY OF THE LINGUAL TOXSIL. 

The lingual tonsil is composed of tissue analogous in all respects 
to the lymphoid tissue situated between the palatal folds and in the 
vault of the pharynx. This tissue exhibits similar pathogical 
changes wherever found and in its enlarged state at the base of the 
tongue causes peculiar symptoms which are very apt to be misinter- 
preted. When we consider that hypertrophy of the lingual tonsil 
must impede the action of the epiglottis and the movements of the 
tongue it is easy to understand how functional disturbances may 
result. It is a notorious fact that changes in the lymphoid tissue in 
this situation are often met with late in life and in the female sex. 

The symptoms which it causes van' greatly in different persons. 
They are dependent not so much upon the degree of the hyper- 
trophy as upon the temperament of the individual. A moderate 
amount of hyperplasia, in some cases, excites an extraordinary 
degree of disturbance. A sense of fullness and tickling in the throat 
and a constant desire to clear the passage by the act of hacking or 
coughing are most often complained of. The condition is a serious 
one in those who use the voice, either in singing or public speaking. 
The effort to overcome the mechanical obstacle offered by a mass of 
lymphoid tissue at the base of the tongue demands the exercise of 
muscles which should not be employed in voice formation; and, in 
consequence, the patient soon becomes hoarse and tired, and may 
actually lose his voice for a time. Finally structural changes are 
engendered in some part of the vocal apparatus productive of partial 
or complete aphonia. Reference has already been made to the 
morbid conditions of the vocal bands met with under these circum- 
stances. A number of reflex symptoms have been detailed in the 
line of neuralgic pains, asthmatic attacks, spasm of the glottis, etc., 
which are comparatively rare occurrences. R. Levy divides these 
cases into six classes. First, those attended merely by discom- 

238 



HYPERTROPHY OF THE LINGUAL TONSIL. 



2 39 



fort, or paresthesia. Symptoms may have been excited and the 
mind of the patient fixed upon this locality by swallowing a foreign 
body or a rough particle of food, and the patient seeks to be relieved 
of something which he imagines is still sticking in his throat. Some 
of these people consult a physician because they apprehend cancer 
or tuberculosis. In a second class cough is a very persistent and 
distressing symptom, which is only temporarily controlled by seda- 
tives, but yields promptly after the use of the galvanocautery in 
adults and in children to swabbing with tincture of iodine and 
glycerine. Third, dysphonia, vocal fatigue, throatache and impure 
tone production are especially noted in singers, to whom these condi- 
tions are of the utmost moment. Fourth, dyspnea, resembling that 
caused by spasm_of the larynx and occurring chiefly at night, may 




Fig. 106. — Hypertrophy of Lingual Tonsil. (Grunwald.) 

be so extreme that the patient dreads going to bed, and eventually 
the general health may suffer from loss of sleep and mental distress. 
Fifth, dysphagia may exist to a degree sufficient to impair nutrition, 
and sixth, hemorrhage may occur from an associated lingual varix. 
The last is certainly rare. Nevertheless in view of the extreme dis- 
quietude caused by the appearance of blood in the sputa it is a satis- 
faction to be able to assure a patient that it comes from the base of 
the tongue and not from the lungs. 

The diagnosis is usually made without difficulty by simple in- 
spection with the laryngeal mirror (Fig. 106). Irregular masses of 
lymphoid hyperplasia, frequently covered with enlarged veins, are 
seen which sometimes incarcerate the tip of the epiglottis. The 
masses are in some cases so large as to be distinctly pedunculated 



240 DISEASES OF THE NOSE, THROAT AND EAR. 

and are visible without the mirror through the open mouth. Pro- 
trusion of the tongue fails to separate its base from the epiglottis. 
A most conspicuous feature in the picture is often the remarkable 
size and number of varicose vessels. The presence of multiple 
turgid vessels should of course restrain us from the use of cutting 
instruments in this region. In elderly people lingual varix is very 
commonly observed and rarely possesses any significance. It may 
exist without much hypertrophy of lymphoid tissue, and may be 
associated with varicose vessels in other situations. 

The symptoms are sometimes relieved temporarily by painting 
the region with cocaine. In many cases the condition is aggravated 
by impaired general health, neurasthenia, or deranged digestion. 
Improvement in these particulars under general medication, com- 
bined with the local application of astringents, often effects a cure. 
In other cases, persistent cough and phonatory disturbance demand 
more energetic treatment and we are compelled to resort to destruc- 
tion of the masses by the use of caustics, or the electro-cautery, or to 
removal by means of the snare or the knife. The process of cauteri- 
zation with electricity is painful and disagreeable while effective if 
perserved with. The knife in this region is dangerous for the reason 
that the parts are vascular and it is not an easy place in which to 
control bleeding by pressure. The cold-wire snare is, perhaps, 
equally effective and certainly safer, but we need for this purpose an 
instrument of unusual power. Various lingual tonsillotomes have 
been proposed shaped very much like the guillotine used in excising 
the faucial tonsil, but somewhat curved to fit the dorsum of the 
tongue (Fig. 107). The reaction from the operation of removing 
these masses is sometimes considerable, especially when the electro- 
cautery has been used, and is best relieved by holding pieces of 
cracked ice in the mouth, or by the application of cocaine. 

The lingual tonsil is no doubt subject to inflammatory attacks 
precisely as are the other lymphoid masses in the " adenoid triangle," 
or "lymphoid ring." In the opinion of H. L. Swain, who has 
seen a number of cases, the condition is often overlooked. A series 
of sixteen cases has been reported by Seifert and almost an equal 
number by other observers. They may be less frequent, or perhaps 
less clearly recognized, than similar affections of the palatal tonsils, 
or possibly the intensity of the process in the latter overshadows a 
concomitant trouble at the base of the tongue. Phlegmonous 



ABSCESS OF THE LINGUAL TONSIL. 241 

inflammation, or " lingual quinsy" is a very serious disease. It 
rarely extends beyond the anatomical limits of the tonsil, but when 
it does invade the floor of the mouth it resembles a true "angina 
Ludovici." The constitutional disturbance is extreme, as indicated 
by the high temperature and rapid pulse. Pain is severe and con- 
stant and is intensified by attempts to speak or swallow and by the 
slightest movement of the tongue. The swelling may be enormous 
so that the tongue protrudes from the mouth and there is a continu- 
ous dribbling of saliva. The breath becomes horribly fetid and 
the tongue is covered with a thick leathery fur. Dyspnea may 




Fig. 107. — Roe's Lingual Tonsillotome. 

result from swelling or from edema of the epiglottis and the vesti- 
bule of the larynx. The danger from this source, or from asphyxia- 
tion following a rupture of the abscess, is considerable, especially 
in the aged and in those weakened by long illness. 

It is difficult or impossible to introduce the finger for palpation, 
and even if we succeed a sense of fluctuation is very obscure and 
indecisive. We may be forced to make a diagnosis without even 
a glimpse of the parts involved. 

From this brief description it must be clear that this is a much 
more serious and alarming process than similar affections of the 
other tonsillar masses. Fortunately it is much more infrequent. 
Doubtless some of the cases of so-called "abscess of the tongue." 
and very likely the fatal cases of alleged "quinsy" should be classi- 
fied under this designation. 

The causes acting to excite inflammation of other lymphoid tissue 
16 



242 DISEASES OF THE NOSE, THROAT AND EAR. 

operate equally in the case of the lingual tonsil. A depressed state 
of the general health, a rheumatic diathesis, or a foreign body may 
be concerned as factors in the causation of inflammation of the glands 
at the base of the tongue. An interesting example of the last- 
mentioned cause was observed by the author many years ago, in 
which a wisp of straw taken into the mouth with a draught of water 
became engaged in one of the lingual follicles. After several days 
of extreme distress the patient was relieved by spontaneous rupture 
of the abscess. 

The general treatment should be conducted on the lines laid down 
in speaking of the faucial tonsils. Early and free incision for the 
release of pus, and even if the presence of pus cannot be demon- 
strated, is clearly indicated. The best instrument for this purpose 
is a sharp-pointed curved bistoury with a rather short thin blade. 
Hemorrhage is apt to be very free. If an abscess is opened and pus 
evacuated the relief of symptoms is immediate, and in any case 
scarification does no harm. Hot alkaline and antiseptic mouth- 
washes and hot fomentations externally are usually soothing and 
grateful. The necessity for stimulating and supportive treatment 
may be urgent. 

Neoplastic formations and tumors in the region of the lingual ton- 
sil are rather uncommon. Among the most interesting of the latter 
may be mentioned accessory thyroid tumors, instances of which have 
been reported by H. T. Butlin, J. E. Schadle and others. A remark- 
able phenomenon in a case recorded by Schadle was presented in the 
form of vascular turgescence of the tumor during a period of sup- 
pressed menstruation. This growth was removed by McBurney by 
an external incision, its real nature not having been previously fully 
determined. In a case reported by Theisen an accessory thyroid as 
large as a hen's egg was observed deeply embedded in the base of 
the tongue. It appeared to be quite vascular, which fact together 
with the patient's age (67) was thought to preclude operation. The 
tumor diminished somewhat in size under internal use of thyroid ex- 
tract. An interesting point in the history is that the woman had a 
goiter in early life, all trace of which had disappeared. 

RETRO-PHARYNGEAL ABSCESS. 

Retro-pharyngeal abscess is a plegmonous inflammation involv- 
ing the cellular, or the lymphoid, tissues of the pharyngeal wall. In 



RETROPHARYNGEAL ABSCESS. 243 

many cases no cause for the suppuration can be discovered; in a 
few, it succeeds abscess formation in the cervical region; in others, 
it is secondary to caries of the vertebrae; in a small proportion of 
cases it is a sequel of an exanthem; and, finally, it may be produced 
by a foreign body. In a large number of cases, in children, the 
lymphoid tissues are evidently the seat of the disease and the 
course of the lesion is usually extremely slow. In adults, on the 
other hand, the abscess is more apt to simulate suppuration in 
cellular tissues elsewhere and is attended by more disturbance and 
local reaction. In children it is usually considered a sign of struma. 
Its development is very slow, the general health of the child becomes 
gradually impaired, food is refused as the difficulty in swallowing 
increases and, finally, a peculiar throaty quality of the voice becomes 
pronounced and there is more or less impediment to breathing. The 
dyspnea ultimately becomes very alarming and, in fact, may be the 
first symptom to draw attention to the throat. 

On examination the pharynx is seen to be occupied by a bulging 
tumor, on one side of the middle line over which the mucous 
membrane is glazed and tense. Usually the tumor occupies the 
oropharynx but, in rare instances, it is much lower and may not 
be visible by direct inspection. In adults the local symptoms may 
be much more acute at the onset and there is more or less constitu- 
tional disturbance. Pain referred to the faucial region aggravated 
by swallowing directs attention at once to the throat. Obstruc- 
tion to swallowing is so considerable as to interfere with nutri- 
tion. Breathing is seldom seriously impeded. The appearances 
presented resemble those of an abscess in other situations and the 
diagnosis of pus formation may be confirmed by palpation with the 
finger; a peculiar elastic sensation or actual fluctuation may be 
recognized. 

If left to itself an abscess in this situation usually discharges 
in a week or two; but, in children, it sometimes runs a very chronic 
course, extending over many weeks. In the latter case, while the 
local disturbance is not very serious, there is danger that the patient 
may succumb in consequence of impaired nutrition. In children 
and in individuals very much reduced in strength, or advanced 
in years, spontaneous rupture of the abscess, or opening by incision 
is attended by some risk from entrance of pus into the larynx. 
In milder cases, simple incision with a guarded bistourv and evaeua- 



244 DISEASES OF THE NOSE, THROAT AND EAR. 

tion of the pus results in cure. Erosion of an artery with fatal 
hemorrhage has occurred in several cases on record. Edema of 
the glottis is a complication of especial seriousness in weak children. 
In some instances of extensive suppuration external opening of the 
abscess is required by an incision along the anterior border of 
the sterno-cleido-mastoid muscle. This more formidable operation 
is demanded only in cases of extraordinary extent, or where the 
abscess is seated low down in the pharynx. Ordinarily simple punc- 
ture or incision through the mouth under local anesthesia will suffice. 
In unmanageable children a small quantity of chloroform is required. 
Local applications are useless since the formation of pus is generally 
inevitable and rapid and its evacuation is necessary. There is 
seldom necessity for special dressing of the abscess cavity except 
after an external operation. During convalescence a semi-fluid 
diet and the use of antiseptic sprays and gargles, especially after 
taking food, are plainly indicated. Attention should be given to 
the general health and the correction of a strumous diathesis. 

PHARYNGO-MYCOSIS. KERATOSIS. 

Mycosis of the pharynx, first described by B. Fraenkel, is a term 
applied to a fungous development which sometimes appears upon the 
surface of the tonsil, upon the lymphoid tissue at the base of the 
tongue, or within the follicles distributed over the mucous membrane 
of the pharynx. The vault of the pharynx also is often invaded. 
It consists of a deposit of spores of the leptothrix buccalis, a fungus 
which is almost invariably present in the oral cavity and yet its 
transference to the fauces is comparatively rare. 

Impaired general health is usually regarded as a predisposing 
cause and, in a large proportion of those subject to it, digestive 
derangements are pronounced. In some cases the saliva has 
an acid reaction. In a small number of cases it has been observed 
to follow tonsillitis and diphtheria, but there is no proof of any 
special relationship. In a large majority of cases the patients seem 
to be in perfect health, and absolutely no constitutional disturbance 
is observed. 

The symptoms which it induces are not very pronounced 
It is not at all uncommon to discover deposits of mycosis in 
those who are unaware of any trouble whatever. Occasionally 



MYCOSIS OF THE PHARYNX. 245 

slight hacking cough and a feeling of irritation in the pharynx are 
present, but there is never acute local inflammation, except as a 
coincidence. The appearances it presents are almost unmistakable; 
yet it is not a rare experience to see cases that have been diagnosed 
and treated as follicular tonsillitis. Such an error may occur when 
the fungous growth is unusually exuberant, or is attended by inflam- 
matory conditions. The uniform absence of the latter and the color- 
less appearance of the exudate differentiate it positively from diph- 
theria. It occurs in the form of milky white filamentous tufts 
projecting from the surface of the membrane, usually from a 
follicle. If one of these projecting masses be seized with the forceps 
it frequently may be drawn from the lacuna with ease. Sometimes 
its removal is followed by the escape of a little blood. The condi- 
tion is perfectly innocuous and spreads slowly. Having been re- 
moved by mechanical means or by destructive agents it frequently 
shows a marked tendency to recur. 

The treatment of the disease is very troublesome since success 
depends upon the complete and thorough destruction of all the 
spores; should any be overlooked they will be sure to reproduce 
themselves. A variety of agents have been employed, including 
absolute alcohol, perchloride of iron, pure carbolic acid, iodine prep- 
arations and all the stronger astringents, but the galvano-cautery 
gives the best results. Large masses of lymphoid hyperplasia, which 
offer a favorable site for the development of the mycotic product, 
should be removed. The milder cases which give but very few 
symptoms may, very properly, be let alone, or be treated by simple 
antiseptic gargles and the correction of possible digestive disturb- 
ances. The galvano-cautery and pyoctanin are relied upon by R. P. 
Lincoln in the treatment of this disease. The latter is used in 
powder rubbed briskly into the affected region daily until all signs 
of the growth disappear. Enlarged follicles, or hyperplastic masses 
of lymphoid tissue containing the tufts may be burned away with 
the electric cautery or excised. 

A membranous disease presenting the gross appearances of a gen- 
uine mycosis, according to Kyle and others, is a keratosis beginning 
in the submucosa. It is pronounced not bacterial, although the 
leptothrix has been found in certain cases, probably as an accidental 
occurrence. This is the view elaborated by Siebenmann, who 
maintains that the bacteria are purely saprophytic and that they 



246 DISEASES OF THE NOSE, THROAT AND EAR. 

are in no respect etiological. Similar conclusions are reached by 
Geo. B. Wood, who thinks that the peculiar formation of keratosis 
is the result of a low grade of inflammation sufficient to stimulate 
the growth of normal epithelium and not intense enough to lead 
to the pus formation of an acute process or the accumulation 
of cheesy masses characteristic of a chronic lacunar amygdalitis. 
Brown Kelly expresses the opinion, based on an exhaustive study 
of the subject, that there are two distinct diseases, mycosis and 
keratosis, which present the following differences: 

1. Keratosis is found in adults, mycosis at any age. 

2. The cause of keratosis is unknown, mycosis is due to some 
derangement of buccal secretion or of the digestive tract, or possibly 
to a rheumatic or other diathesis. 

3. The symptoms of keratosis are slight or absent, those of myco- 
sis are pronounced. 

4. In keratosis the mucous membrane is normal, in mycosis 
inflamed. 

5. The exudate of keratosis is tough, firmly adherent, and assumes 
characteristic shapes, that of mycosis is soft and easily detached. 

6. Keratosis affects only the tissues of Waldeyer's ring, mycosis 
may occur at any part of the mucous membrane. 

7. Keratosis, except for the presence of leptothrix, bears no re- 
semblance, while mycosis is similar to thrush, sarcina and other 
mycoses. 

8. Keratosis is not influenced while mycosis may be cured by local 
applications. 

These views are in a sense a compromise between Heryng's theory 
as to keratosis and that of Miller, who describes several different 
forms of bacilli as causative factors. According to the latter, none 
of these organisms can be cultivated in any known media, while 
Jacobson claims to have cultivated the leptothrix on potato. The 
pathogenic nature of the leptothrix is thought to be proved by the 
fact that this organism was found by Pearce in two cases extending 
deeply into healthy tissues. Jonathan Wright believes that the thick- 
ening of the epithelial lining of the affected crypts is a result of a 
chronic inflammatory process caused by the irritative action of the 
mycelium. Similar phenomena are often observed in other parts 
of the air tract. By staining sections of tissue containing the 
mycelium with gentian violet and Gram's iodine he was able to 



KERATOSIS OF THE PHARYNX. 247 

demonstrate the bacillus maximus buccalis as well as the leptothrix. 
He has been unable to confirm the observation that the mycelial 
threads sometimes penetrate the epithelial layer and even the sub- 
jacent tissues. On the contrary he has always found them only in 
the lacunae surrounded by innumerable spores. 

Thus there appears to be hopeless confusion as to the importance 
of the role played by the various organisms, and after all the lesion 
is of interest chiefly as a microscopic picture and not by reason of 
any marked clinical signs. 



CHAPTER XV. 

TONSILLITIS. DIPHTHERIA. CIRCUMTONSILLAR ABSCESS, OR 
QUINSY. ULCERO-MEMBRANOUS OR DIPHTHEROID ANGINA. 

TONSILLITIS. 

Inflammation of the tonsil may involve the mucous membrane 
covering the gland, that lining the crypts, or the substance of the 
organ itself; the first is called superficial, the second, lacunar or fol- 
licular, and the last, parenchymatous amygdalitis. These are prac- 
tically stages of the same disease; the last is frequently complicated 
by the formation of a phlegmon, in that case constituting a circum- 
tonsillar abscess, or quinsy. The attempt has been made to classify 
inflammation of the tonsils on a bacteriological basis, but clinically 
we find so many varieties of microorganisms in healthy as well as 
in inflamed throats, some of them pathogenic and others non- 
pathogenic, that such a classification seems to be of little or no prac- 
tical value. There is an accumulation of evidence to show that the 
tonsils may be the avenues by which morbid germs enter the system 
and cases in which disease has affected the lungs, the pleura, the 
meninges and the joints through the tonsillar crypts are fully 
established. 

Considerable discussion has taken place as to the infectiousness 
of simple inflammation of the tonsils, and while there seems to be 
some ground for accepting the theory of contagion it must be 
admitted that in nearly all cases a predisposition to the disease 
exists and that where epidemics occur the victims are exposed in 
general to similar atmospheric conditions. Moreover, it is a matter 
of common observation that instead of being protected against 
succeeding attacks, as is true of contagious diseases, one who has 
suffered from tonsillitis is very liable to recurrence. 

A predisposing cause of tonsillitis is found in certain local morbid 
conditions such as affect lymphoid structures generally. Exposure 
to cold is recognized as an exciting cause, especially in individuals 
who have been overheated or are in a condition of depressed general 
health. There is reason to believe that, in a large proportion of 

248 



ACUTE TONSILLITIS. 249 

cases, the rheumatic diathesis prevails either in the individual or 
in the family and, from this standpoint, the theory of heredity gains 
some credence. In a certain number of cases errors in diet and 
functional irregularities in the female seem to induce an attack. 
In many no cause can be discovered. In acute cases it is observed 
that the involvement of one tonsil is followed after a few days by 
that of the other. In some both tonsils are affected at the same time 
and in all there is more or less simultaneous congestion of the fauces 
and pharynx. 

We recognize acute and chronic forms of tonsillitis, and from a 
clinical and therapeutic standpoint it is unnecessary to make any 
further discrimination. There is usually no difficulty in identi- 
fying an acute amygdalitis and in fact a diagnosis is generally 
made by the patient himself. The most conspicuous local symp- 
toms are more or less intense pain on swallowing accompanied by 
a sense of fullness and obstruction in the fauces. There is some 
sensitiveness on external pressure in the tonsillar region and indeed 
all the muscles of the neck are quite stiff and painful. Pain is felt 
in the ear of the affected side and almost constant tinnitus aurium 
may be present. Constitutional disturbance is usually decided. 
Headache, muscular pains, anorexia, chills and high temperature 
comprise a train of symptoms apparently out of proportion to a 
local disturbance of such simple character. On inspection of 
the affected parts the tonsils are seen to be red and turgid, and the 
palatal folds, the velum itself and the uvula are swollen and edema- 
tous. If the crypts are involved their orifices are indicated by accu- 
mulations of yellowish-white secretion which may coalesce into 
a membranous formation resembling the exudate of diphtheria. 
If the cervical glands are swollen, which is apt to be the case 
at a late period or in very intense forms of amygdalitis, the 
diagnosis is quite dubious. The voice is thick and muffled, or 
husky from laryngeal congestion, and the relaxed condition of the 
vocal bands may require attention after the subsidence of the 
pharyngeal inflammation. The nasopharynx, the Eustachian tubes 
and the middle ear may become involved in an inflammatory process, 
especially in those who have had previous ear trouble or who are 
run down in health. 

In the chronic form of tonsillitis there may be little or no enlarge- 
ment of the gland but the lacunae which compose it are clogged 



250 DISEASES OF THE NOSE, THROAT AND EAR. 

with epithelial debris, decomposing secretions and bacteria which 
are a source of local irritation and doubtless cause a modified form 
of general septic infection. Such tonsils are prone to acute exacerba- 
tions when their volume is temporarily very much increased. 
We are familiar with several varities of reflex disturbance from these 
chronic inflammatory conditions referable to the acts of breathing 
and swallowing and, in some cases, the quality of the voice as well 
as its power is distinctly impaired. The odor of the breath is 
markedly offensive in cases of long standing in which the secretions 
have been retained in the lacunas, and frequently little masses or 
balls of yellowish inspissated secretion are extruded which emit a 
very foul odor on being crushed. The theory that this condition 
provokes the formation of "singers' nodes," propounded by F. E. 
Miller, has not been fully confirmed. 

In the treatment of acute tonsillitis the first thing to be done is 
to administer an active purge; a saline laxative is the most satis- 
factory. If febrile reaction is prominent the internal use of drop 
doses of aconite every hour is efficacious. Quinine is very com- 
monly prescribed in this disease, especially when fever is marked, 
but probably without good reason, and, moreover, the detrimental 
effect of this drug upon the ears, which in many of these cases 
are already to some extent impaired, should be remembered. 
Chlorate of potash in tablets containing five grains each, one to be 
dissolved in the mouth every two or three hours, seems to be soothing 
in cases of mild type. A combination of chlorate of potash with 
tincture of the chloride of iron is believed by many to have a 
specific effect upon these septic processes, but there seems to be no 
valid foundation for this view, and certainly in my experience cases 
do equally well under doses less nauseous and less disturbing to the 
digestive tract. 

Guaiac, in the form of lozenges or as an ammoniated tincture, 
may be given every two or three hours until the bowels are acted 
upon. The salicylates, and more recently salol, have been used 
with satisfaction especially in cases in which the rheumatic diathesis 
is conspicuous. Some of the coal-tar products, especially acetan- 
ilide and phenacetin, are popular, but should be used cautiously. 
During convalescence it is found necessary to resort to general 
tonics, since there often results a remarkable degree of systemic 
depression. 






ACUTE TONSILLITIS. 25 1 

Locally the use of sprays, inhalations and pigments is decidedly 
preferable to that of gargles. The act of gargling in acute inflam- 
mation is a source of irritation and any good accomplished must be 
thus more or less counterbalanced. Bicarbonate of soda in powder 
applied with a spatula sometimes gives marked relief. Externally 
water compresses or poultices of flaxseed are a source of comfort. 
In the early stages of an acute inflammation of the tonsils the applica- 
tion of cold by means of Leiter's coil, or icebags, is serviceable. 
As a rule these cases are seen too late to be amenable to cold applica- 
tions and heat is more grateful and effective. Friction of the neck 
with some stimulating embrocation is thought to do good by diverting 
the blood from the inflamed region to the surface. Swabbing the 
inflamed tonsil with pure tincture of iodine is said by Floersheim to 
give prompt relief even when suppuration seems imminent, but his 
experience has not been fully corroborated. In fact in some cases 
a decided aggravation of the subjective symptoms has been noted. 
It is claimed that an attack may be aborted by painting the fauces 
with a strong silver nitrate solution (i dr. to i oz.). To most people 
this is an extremely disagreeable application and its value is doubtful. 
A mild solution is certainly irritating and useless, and the strong 
solution should be employed only in the early stages. Its mode 
of action is undetermined, whether as an antiseptic or by substituting 
a simple for an infective inflammation. In the experience of some 
attacks of follicular tonsillitis have been frequently aborted "by 
cleansing the tonsils with a saline solution, swabbing with peroxide 
of hydrogen, and then spraying with suprarenal, and repeating this 
treatment in twelve hours" (O. T. Osborne). A certain amount of 
suspicion always attaches to alleged " abortive" methods of treat- 
ment but that last mentioned has at least the negative advantage of 
being harmless. When several agents are used at the same time or 
successively it is rather difficult to decide which should receive credit 
for the effects observed. Pigments of menthol, 20 grains to the 
ounce of fluid albolene, applied at short intervals often give great 
relief. In the interval of the attacks any chronic morbid condition 
should be relieved or corrected as a prevention of recurrence. 

Chronically inflamed tonsils assume a great variety of shapes. 
Frequently portions may be so enlarged as to permit of exci- 
sion. Many are flat and so hidden behind the pillars as to be 
quite inaccessible. Others are riddled by distended crypts nunc 



252 DISEASES OF THE NOSE, THROAT AND EAR. 

or less filled with caseous material, a variety known as the "honey- 
combed" tonsil. When the tonsils are not enlarged the treatment 
consists in emptying the lacunae by scooping out the caseous contents 
and then obliterating the diseased crypts by the use of some chemical 
caustic or the galvano-cautery. If the tonsil is enlarged the best 
treatment is removal with the guillotine or the wire snare, hot or 
cold, according to indications. In case radical interference be 
declined something may be done by applications of strong tincture 
of iodine, or by inserting into the crypts a probe charged with 
trichloracetic acid. Substantial results are obtained only by 
prolonged use of this method and with tonsils in which hyperplasia 
is not a prominent feature. In some of these cases habitual daily 
gargling with antiseptic solutions seems to be of benefit. The 
muscular exercise required by the act serves to empty the follicles 
clogged with detritus and is a healthy stimulant to the function of 
all the faucial region quite independent of any medicinal quality 
possessed by the fluid in use. By the ordinary mode of gargling 
only the anterior surfaces of the velum and tonsils and the dorsum 
of the tongue are reached. It is possible, however, for some indi- 
viduals with a little practice to throw the fluid into the nasopharynx, 
or even the larynx, but the advantage of the latter feat in pharyngeal 
gymnastics is doubtful. Laryngeal gargling is far from easy, but 
may be effected by the method of Guinier, described as follows. 
A small quantity of fluid is taken into the mouth, which is held open. 
The head must not be thrown back lest the desire to swallow be 
excited. While the lower jaw is protruded so as to draw forward 
the epiglottis the patient attempts to phonate any vowel sound, 
when the fluid at once finds its way into the larynx and bathes all 
the region above the vocal bands, provided the tendency to swallow, 
or to take an inspiration, can be resisted. The method of von 
Troeltsch, modified by Hagen, for gargling the pharynx is some- 
what easier. The mouth being about half full of fluid is held open 
while a partial act of swallowing is attempted. This carries the 
fluid well into the pharynx where the expired air is made to gurgle 
through it in the usual way, as long as possible. When the process 
of exhalation is completed the tongue is placed firmly against 
the upper incisor teeth and by a quick forward jerk of the head the 
fluid is ejected, much of it passing into the naso-pharynx and out 
by the nostrils (H. L. Swain). Frequent repetition of the attempts 



DIPHTHERIA. 253 

at swallowing while the mouth is open dilates the pharynx, relaxes 
the velum and thus favors the escape of the fluid by the nose, pro- 
vided there is no nasal obstruction. The solutions used in this 
way should be saline, alkaline, or mildly astringent, and should be 
looked upon merely as adjuvants to other therapeutic measures 
and modes of local medication. 

A follicular tonsillitis in the acute stage is not to be regarded as a 
trivial matter. Cases in which septic absorption, followed by gland- 
ular suppuration, suppression of urine and other complications, has 
developed are well authenticated. Cardiac and arthritic complica- 
tions of a sore throat are among the possibilities, and even appendi- 
citis is now classed with the manifestations of " tonsillogenous 
bacteriemia." Even in the absence of these disasters the affection 
is one calling for the most careful supervision, both on account of the 
immediate discomfort entailed and because of the subsequent 
systemic depression. 

DIPHTHERIA. 

It is not proposed to make an exhaustive review of the subject of 
diphtheria but it is important to be able to differentiate its local 
phenomena from those of other diseases which it resembles. 

The early diagnosis of diphtheria is often extremely difficult and 
there are forms of similar membranous inflammation that are con- 
fusing. A bacterial examination may settle the question but fre- 
quently there is neither time nor opportunity for this and we are 
obliged to rely upon clinical signs. The discovery of the Klebs- 
Loeffler bacillus in connection with a false membrane, is considered 
definitive, but its existence in the pharynx does not necessarily prove 
the presence of diphtheria. Many times the bacillus has been 
found in individuals in perfect health. There must be, there- 
fore, special susceptibility of the individual, or virulence of the 
poison, or possibly a still undiscovered toxin, to determine the actual 
development of the disease. In children the discovery of the bacillus 
even in the absence of local symptoms other than slight sore throat. 
should put us on our guard. Such a case should be isolated until 
all doubt as to the character of the condition has been dissipated. 
It is necessary to make a complete examination of the suspected 
region; small deposits of false membrane may exist at the root 



254 DISEASES OF THE NOSE, THROAT AND EAR. 

of the tongue, or behind one of the palatal folds, where they may 
be overlooked. 

A membrane so firmly attached that its removal causes bleeding is 
probably diphtheritic. Rapid extension of the deposit and invasion 
of the nasal chambers add to the gravity of the prognosis. Involve- 
ment of the larynx, especially in children, is a very serious phe- 
nomenon. Sudden fall of temperature is indicative of collapse 
while a rapid rise means septic absorption. A rapid pulse is not 
necessarily a bad sign but irregularity and weakness are unfavorable. 
Albuminuria occurs in a large proportion of cases but becomes 
serious only when complicated by suppression of urine and other 
signs of severe kidney lesion. In diphtheria the systemic depres- 
sion is out of proportion to the local phenomena. In other words 
we have to deal with a constitutional disease of which the symp- 
toms presented on the mucous membrane are a local expression. 
In an average case the membranous exudate seems not merely 
upon the surface but to be incorporated in the substance of the 
mucosa. The attendant hyperemia differs from that of an acute 
inflammation in being more livid in hue, and the subjective symp- 
toms are distinctly less intense. A non-diphtheritic pseudomembrane 
may be readily removed and its careful detachment is not apt to 
leave a bleeding surface. The color of a diphtheritic membrane is 
usually yellowish white at first, but it soon becomes blackened by 
admixture with blood and necrotic tissue. At the same time a 
decided fetor of the breath is detected and the cervical glands 
are swollen and sensitive. A croupous membrane is thin, glazed 
and white, does not become discolored and is easily detached. In 
follicular tonsillitis the exudate is discrete and indicates the mouths 
of lacunae, or if it becomes confluent does not extend beyond the 
surface of the tonsil. 

There is reason to believe that not every membranous deposit in 
the upper air tract is due to the Klebs-Loeffler bacillus, while on 
the other hand certain non-membranous inflammations owe their 
origin to this organism. True diphtheria is caused by a specific 
bacillus or its toxins, but there are many microscopic organisms 
similar in character which are strictly non-pathogenic. The mor- 
phological features of the diphtheria bacillus are not reliably dis- 
tinctive. The chemical test sometimes employed is not absolute, 
owing to varying degree of acid-producing power in different bacilli. 



CIRCUMTONSILLAR ABSCESS: QUINSY. 



255 



Animal inoculation may furnish satisfactory evidence, provided we 
can exclude the possibility that certain non-diphtheritic bacteria are 
fatal to lower animals. Moreover, pathogenic bacilli may lose their 
virulence in artificial cultures and hence fail to produce an effect. 
Immunization of a control animal with diphtheria antitoxin might 
be conclusive, but this takes time, a point of vital importance in 
diphtheria. Nearly every practitioner has had fatal cases, in which 
the bacteriological testimony was negative, and on the other hand 
has been compelled to keep a suspected patient in quarantine for 
weeks solely on microscopic evidence. Hence we are forced to 
reach a diagnosis mainly from the clinical history and local appear- 
ances, looking to bacteriology only for the somewhat uncertain con- 
firmation it is authorized to give. 

The following points in tabular form may be serviceable. 



Tonsillitis. 

Begins abruptly, with chill, rapid 
rise of temperature — 104 degrees 
or more — headache, muscular pains 
and general malaise. 

Tonsils swollen and covered by an 
exudate in the form of a non-adher- 
ent pseudomembrane, or more often 
the mouth of each separate follicle 
is clogged with yellowish white se- 
cretion. 

Spots or patches of membrane easily 
brushed off without causing bleed- 
ing and seldom reform. 

Exudate is limited to the follicles or 
surface of the tonsil and the mucous 
membrane is uniformly red. 



The bacilli of a simple inflammatory 
process are present. 



Diphtheria. 

Comes on gradually, usually without 
chill. 

Moderate rise of temperature, vomit- 
ing and albuminous urine. 

Tonsils not especially large unless pre- 
viously hypertrophied, but more or 
less covered by thick adherent mem- 
brane. 

Cervical glands apt to be swollen and 
sensitive. 

Membrane removed with difficulty 
and exposed surface bleeds. Re- 
turns in a few hours. 

Membrane may be found almost any- 
where on the mucous surface which 
is not intensely red, but is usually 
dark red or livid around the mem- 
branous deposit. 

Pathognomonic ,Klebs-Loeffler bacilli 
usually found. 



CIRCUMTONSILLAR ABSCESS; OR QUINSY. 

Circumtonsillar abscess, or quinsy, is an acute inflammation of the 

tissues contiguous to the faucial tonsil as well as of the gland itself 
resulting in the formation of pus. In a large proportion of cases 



256 DISEASES OF THE NOSE, THROAT AND EAR. 

the focus of suppuration is located at the upper border of the tonsil 
and involves the soft palate. In rare instances it occurs behind 
the tonsil simulating retro-pharyngeal abscess; and, still less 
frequently, the pus is incarcerated underneath the tonsil which 
is pushed into the faucial space without being itself especially 
affected. Abscess of the tonsil proper is a rare occurrence, but when 
pus is formed in the situation last referred to it is not unusual for it 
to escape through one of the tonsillar crypts. 

The valuable researches of J. L. Goodale show some interesting 
facts regarding tonsillar or intrafollicular abscesses. In most cases 
the intratonsillar process was found alone, in a few it was accom- 
panied by circumtonsillar inflammation. There are no clinical 
signs which define an abscess in a follicle, except that a severe 
grade of infection is indicated by more profound constitutional 
disturbance than is met with in simple proliferative amygdalitis. 
Suppurative foci are often numerous, and in such case the strep- 
tococcus pyogenes is the most abundant form of micro-organ- 
ism. The crypts contain a large amount of fibrinous exudate. 
In cases accompanied by circumtonsillar inflammation the inter- 
follicular lymph channels and the connective tissue lymph spaces 
near the base of the tonsil are crowded with polynuclear neutrophiles. 
It is surmised, although the evidence is not yet complete, that an 
intrafollicular abscess is not of embolic origin but is a sequel of 
primary infection of a crypt by the streptococcus pyogenes and that 
circumtonsillar inflammation is due to discharge of a tonsillar abscess 
into the efferent lymph channels. 

Quinsy is a rare disease in childhood and the tendency to it dis- 
appears with advancing years. In exceptional cases a first attack 
occurs in late adult life. In children the natural objection to an 
examination makes it far from easy to reach a diagnosis. Fixation 
of the lower jaw, always symptomatic, adds to the difficulty. If 
the finger can be inserted into the mouth a unilateral sometimes fluc- 
tuating tumor may be detected. The necessity of protecting the 
examining finger, or using a mouth-gag, is especially important. 
Pain and often torticollis together with marked constitutional dis- 
turbance are present. The danger from edema, or spontaneous 
rupture of the abscess in a child is far greater than in an adult. 

The causes of quinsy are not always evident. Exposure to cold 
is a recognized exciting cause and seasonal influences are very 



CIRCUMTONSILLAR ABSCESS: QUINSY. 257 

marked, cases being much more frequent during the spring and fall 
months than at other periods of the year. It seems to be an heredi- 
tary disease, or at least many cases occur in the same family. It is 
sometimes possible to get a distinct history of rheumatism in the 
individual or in the family; although it is perhaps less frequent 
in this than in other forms of amygdalitis. Previous enlargement 
of the tonsil seems to provide a tendency to inflammation, although 
cases are often observed in which the tonsillar tissue itself seems 
to be but little, if at all, hypertrophied. 

Many cases begin as a simple acute lacunar amygdalitis. An 
attack of quinsy is usually announced by a chill or at least by chilly 
sensations. There are more or less pyrexia and systemic disturbance, 
muscular pains, headache and general malaise. A feeling of discom- 
fort in the fauces soon develops into acutal pain aggravated by swal- 
lowing, and the pain may shoot up toward the ear of the affected 
side. As a rule, in twenty-four to forty-eight hours distinct tumefac- 
tion appears in the classical situation at the upper border of the tonsil 
between the palatal folds. There is some edema of the velum and 
uvula and the function of the velum maybe so impaired as to cause 
regurgitation of fluids into the nose on attempts at swallowing. The 
voice is characteristically altered and muffled, the patient is annoyed 
by accumulation of thick, tenacious mucus in the fauces, the attempts 
to clear the passages by hawking being exceedingly painful. The 
salivary secretion is markedly increased and inability to dispose of it 
adds to the patient's discomfort. Fortunately the affection is usually 
limited to one side although there may be consecutive inflam- 
mation involving the second tonsil, If allowed to pursue its course 
spontaneous rupture of the abscess may take place either through 
the anterior pillar or between the pillars at the upper border of the 
tonsil. 

From the symptoms that have been detailed there should be no 
question in making the diagnosis- of quinsy. In some instances 
digital examination gives a positive sense of fluctuation but it is 
not always to be relied upon since the pus may be so deeply seated 
as to fail to give the characteristic sensation on palpation. 

Cases are on record in which quinsy has been mistaken for other 
lesions; among them, aneurysm, malignant disease, diphtheria and 
syphilis; but, after a careful study, such mistakes seem hardly pos- 
sible. In a case of aneurysm, supposed to be quinsy, a bistoury was 
17 



258 DISEASES OF THE NOSE, THROAT AND EAR. 

plunged into the tumor with the result of producing hemorrhage 
which was controlled only by ligation of the carotid artery. In this 
case palpation had previously detected pulsation which should have 
been accepted as a warning. In malignant disease there is usually 
more or less of an ulcerative process which does not occur in quinsy; 
while the rapid development of peritonsillar inflammation tends 
to exclude malignancy. With diphtheria there is probably more 
danger of confusion, at least in the early stages; but enlarged cer- 
vical glands, albuminuria and the presence of bacilli in the exudate, 
together with the absence of very marked or intense local symptoms 
establish a diagnosis of diphtheria. A syphilitic gumma of the 
tonsil or in its neighborhood, when inflamed, resembles quinsy, 
but it is rare to have acute symptoms in connection with a gum- 
matous process and, in the majority of cases, we discover other mani- 
festations of syphilitic infection. 

As a rule, the pus formed in the course of quinsy, succeeds in find- 
ing an outlet, the patient obtains relief from painful symptoms by 
rupture or puncture of the abscess and recovery ensues. The prog- 
nosis, under most circumstances, is good. In some cases, the proc- 
ess of suppuration is slow, the tissues enclosing the pus being so 
brawny and tough as to yield slowly to the pointing of the abscess. 
The condition is practically converted into one of chronic abscess 
of the tonsil. In other cases, when the patient is very reduced in 
strength or advanced in years, there is danger from the escape of 
pus into the air-passages and the occurrence of asphyxia, or the pus 
may find its way into the mediastinum by way of the pharyngo- 
maxillary fossa. A fatal result may follow from absorption of pus 
and the formation of metastatic abscesses, thrombi, etc. Such 
occurrences are extremely rare. The pus may bore its way through 
the wall of a neighboring blood-vessel and lead to the occurrence 
of hemorrhage. Happily, the large blood-vessels in the vicinity are 
protected by a considerable amount of connective tissue and they 
are not easily reached, although a number of cases in which the 
internal cartoid artery has been invaded are on record, all terminat- 
ing fatally. 

An interesting contribution to the subject of hemorrhage from a 
circumtonsillar abscess has been made by W. F. Chappell. In 
a case which he reports an abscess was opened by a small incision 
in the usual situation. Four days later a hemorrhage of about six 



TREATMENT OF QUINSY. 259 

ounces occurred and was repeated in still larger amount in four 
hours. It was controlled by astringent applications, but five days 
afterward a third bleeding to about eight ounces was followed by 
persistent oozing. The abscess cavity distended with clots was then 
freely opened and packed with iodoform gauze after having been 
irrigated with hydrogen peroxide. Under daily renewal of this 
dressing the cavity healed and no more bleeding took place. After 
the second hemorrhage an examination of the urine showed albu- 
minuria with epithelial and pus cells and granular casts. During 
convalescence a severe attack of rheumatism involving the muscles 
of the calves and to some extent certain joints occurred, and the 
opinion is expressed that this as well as the nephritis must be attrib- 
uted to the tonsillar abscess. In a search of the literature of the 
subject this observer finds several similar cases and a surprising 
mortality. In most of them the internal carotid appears to have 
been opened by ulceration, in one the lingual artery (Thomas 
Watson), and in one the blood seemed to come from "rupture of a 
small abscess on the posterior surface of the velum" (Brewer). In 
ChappelFs case the ascending pharyngeal artery, seen at the posterior 
wall of the cavity, was suspected. In a collection of 51 cases (28 
fatal) of pharyngeal hemorrhage in connection with suppuration 
discovered by J. E. Newcomb, many interesting points are empha- 
sized. In several the phlegmon was not in the immediate vicinity 
of the tonsil. Spontaneous opening of the abscess occurred in a 
large proportion (33) and the hemorrhage was found to have come 
from a perforation of the internal carotid artery. In 16 cases the 
common carotid was tied, once without any impression on the 
bleeding, eleven times with success, in one both external and internal, 
and in one the common, external and internal were ligated, both 
successful. The danger of hemorrhage arises not only from acutal 
erosion of a vascular wall, but from rupture of a weakened vessel 
consequent upon sudden evacuation of an abscess and is naturally 
greater the longer the pus has been accumulating. Early interven- 
tion for release of pus is clearly indicated. In case of bleeding 
exposure and firm packing of the abscess cavity should be practised 
before resort is made to ligation of the carotid. 

The treatment of quinsy consists, in the early stage, in an attempt 
to abort the disease and prevent the formation of pus. Unless seen 
early it is impossible to accomplish this. Revulsives in the shape 



260 

of hot foot baths, diaphoretics and an active purge sometimes 
succeed, in conjunction with the internal use of a very old fashioned 
but excellent remedy, guaiac. On the rheumatic theory in recent 
years salicylates have supplanted the older drug but are little, if at 
all, more effective and are probably less safe. The alkaline treat- 
ment with bicarbonate of soda recommended many years ago has also 
given good results. It is used internally, as well as locally. The 
tincture of aconite, recommended by Ringer, is also of use. When 
the symptoms are very acute gargles are a source of so much pain 
that they are not only ineffectual but the muscular effort required 
seems to aggravate the local disturbance and so counteract, in a 
measure, any good effect they may have. The objection does not 
apply to the use of sprays or pigments, some of which are found 
to be efficacious. One of the best applications in any form of inflam- 
mation of the tonsils is a combination of the bicarbonate, biborate 
and salicylate of soda, of each equal parts, a teaspoonful of the 
mixture being dissolved in about four ounces of hot w T ater and 
sprayed into the throat, or, if preferred and the parts be not too sen- 
sitive, the solution is used as a gargle. At the same time the 
salicylate of soda is given internally in doses of ten grains every 
two hours until its physiological effects are obtained. Ammoniated 
tincture of guaiac is used as a gargle by adding a tablespoonful to a 
glass of hot milk, a mouthful of the mixture being swallowed every 
hour until the bowels are acted upon. In the early stages external 
applications of dry cold in the form of ice-bags are sometimes of 
service. 

When the foregoing measures appear to have failed and signs of 
suppuration are distinguished, the only resort is to surgical meas- 
ures. If the pus points at the upper border of the tonsil an incision 
should be made through the anterior pillar with a sharp-pointed 
curved bistoury, the blade of the knife being held parallel to the 
fibers of the palato-glossus muscle and directed obliquely upward 
and inward. A small cataract knife is also a very convenient instru- 
ment, its triangular blade making a large vent for the escape of pus. 
The rule followed by Chiari is to make the incision bisect a line 
drawn from the base of the uvula to the last molar tooth. When the 
knife is passed in the situation described there is no risk of striking 
any important blood vessels except, of course, in the existence of 
some abnormality. Usually pus begins to escape before the knife 



TREATMENT OF QUINSY. 26 1 

is withdrawn and relief is immediate. The preliminary applica- 
tion of cocaine does very little good in the way of deadening the pain 
of the cut which is considerable but momentary. The pus may 
be so deep seated as not to be reached by an incision considered 
safe; in such case the insertion of a blunt probe into the cut may 
succeed in opening the abscess wall, and, even if pus does not escape, 
the incision relieves tension and encourages its progress toward the 
surface. Sometimes the wall of a deep-seated abscess may be 
ruptured by plunging an ordinary polypus forceps into the wound 
and forcibly separating its blades. 

In some cases of tonsillar abscess in which an accumulation of pus 
exists at the bottom of crypt or in which the focus of suppuration 
is just outside the tonsillar capsule, a method of treatment revived 
by G. A. Leland is found efficacious although somewhat heroic. 
Through a free vertical incision in the tonsil itself with an angular 
bistoury the finger is introduced and the tissues are forcibly broken 
down. Local anesthesia is usually sufficient. Sometimes a dense- 
walled cavity is opened in which is found a quantity of pu s. Reaction 
is seldom excessive and the relief of symptoms is generally immediate. 
In these cases it is supposed that the trouble begins in a tonsillar 
crypt, thence extending to the circumtonsillar tissue. Breaking 
down the tissues, as suggested by Hoffmann, and called by him 
" discission," may be effected by means of a large stiff probe, but 
the forefinger answers better. 

When pus is not disclosed by scarification the process of suppura- 
tion should be promoted by hot applications externally and by means 
of hot inhalations and gargles. The external application most grate- 
ful and effective is a hot flaxseed poultice which should be large 
enough to cover the whole side of the neck and should be overlaid 
by a piece of oiled silk. When pus evacuates itself, or is released 
by incision, the inflammatory process promptly subsides and prac- 
tically the attack is over. But the tendency to the disease may still 
remain and if predisposing causes such as enlarged tonsils are 
recognized they should be removed. It is not safe, however, to 
guarantee a patient against recurrence of quinsy after partial excision 
of the tonsils, since it not infrequently happens that an attack will 
take place within a few months after a tonsillotomy. Hence the 
necessity of a "tonsillectomy" rather than a tonsillotomy. The 
importance of extirpating the upper part of the tonsil as a preventive 



262 

of peritonsillar phlegmon is insisted upon. The gland is often deeply 
seated in the angle between the pillars to which it may be firmly 
adherent. The ordinary methods of excision do not reach it and 
it must be enucleated by a careful dissection or with a tonsil 
punch. Attention to the mode of life and the habits in general, 
and the correction of a rheumatic tendency will do more to banish 
a predisposition than local treatment alone. An attack of quinsy is 
almost always brought on by overexertion and is favored by a state 
of low vitality. Recovery is apt to be tedious and needs to be 
assisted by tonics and generous diet. 



ULCEROMEMBRANOUS OR DIPHTHEROID ANGINA. 

It must have fallen to the lot of every practitioner of wide expe- 
rience to be puzzled by a form of sore throat resembling diphtheria 
but free from violent constitutional disturbance. In these cases a 
true ulcerative process goes on involving a very limited area or the 
entire surface of the tonsil, extending through the whole thickness 
of the gland or affecting only its superficial portion. The mildness 
of the associated systemic disturbance differentiates it from a con- 
fluent follicular amygdalitis. Usually but one tonsil is involved and 
adjacent parts are not extensively invaded. The submaxillary 
glands of the corresponding side are generally enlarged and remain 
hard some time after the throat symptoms disappear. The gross 
appearance of the membrane suggests diphtheria, but no Klebs- 
Loeffler bacilli and indeed few microorganisms of any kind are to 
be found, except the fusiform bacillus of Vincent, which is uniformly 
present in large numbers and is thought to be the special microbe 
of the disease. Both a bacillus and a spirillum are present, the 
former being fusiform in shape and straight or curved and staining 
promptly with aniline fluids. The fusiform bacillus is found 
normally in the mouth and has been discovered in pus from the an- 
trum and in that of a perilaryngeal abscess; it has not been cultivated 
in artificial media and has not been proved to be pathogenic to ani- 
mals. Although this seems to be a comparatively mild disease, 
Watson Williams asserts that it is very fatal in children. Usually 
the membrane clears off in a week or two and the parts resume their 
former appearance except so far as tissue may have been destroyed 



Vincent's angina. 263 

by ulceration, and even then the resulting deformity is far from 
commensurate with the loss of tissue.* 

In a recent case in my clinic an ulcer occupied the left tonsil and the mucous 
membrane near the last molar teeth. It was irregular in contour, quite deep and 
sloughy in appearance, and was extremely sensitive. The cervical glands were 
implicated and were very hard and tender. Although there was no history 
of syphilis, the young man was put on mixed treatment and in the meantime 
a smear from the surface of the ulcer was examined under the microscope. 
The specimen was found to be crowded with fusiform bacilli. Internal treatment 
was stopped and the ulcer was simply bathed at short intervals with hydrogen 
peroxide. Repair began at once and rapidly progressed. Notwithstanding 
the apparent depth of the ulcer, the parts have healed with hardly a trace of 
damage. 

The average case is much more likely to be confounded with 
follicular tonsillitis or diphtheria, especially the latter. Severe 
constitutional disturbance and clogging of the tonsillar lacunae 
with inflammatory products characterize the former, while diphtheria 
is not an ulcerative disease, until the third or fourth week, by which 
time its nature is usually demonstrated by profound systemic de- 
pression. The microscopic testimony is conclusive. Although the 
proof is not yet absolute, this lesion is probably caused by a 
specific organism for reasons expressed by Sobel and Herrman, 
in a very complete review of the subject, as follows: the presence of 
fusiform bacilli in large numbers, their rapid disappearance as the 
ulceration heals, the scarcity of other microorganisms and the occa- 
sional transmission of the disease from one individual to another. 
The duration of the affection is usually less than three weeks, and 
may be reduced by appropriate treatment. One case (Lemoine) 
lasted seventy days. 

The local treatment which has been found most effective has been 
the application of iodine in some form, preferably Lugol's solution. 
Nitrate of silver, in three to 5 per cent, solution, and 10 per cent, 
chromic acid have also proved serviceable, and recently Siredey has 
recommended pure methylene blue in powder rubbed well into the 
lesions. 

*In a case described by H. Arrowsmith destruction of tissue anil consequent 
deformity were remarkably extensive, in the latter respect showing a striking contrast 
with syphilitic ulceration. 



CHAPTER XVI. 

BENIGN NEOPLASMS OF THE TONSIL. TONSILLITHS. MALIGNANT 

DISEASE OF THE TONSILS. TUBERCULOSIS, LUPUS AND SYPHILIS 

OF THE PHARYNX. NEUROSES OF THE PHARYNX. FOREIGN 

BODIES IN THE PHARYNX. 

Benign neoplasms of the tonsil comprise lymphoma, fibroma, 
papilloma, angioma and lipoma. The first is rarely seen except in 
combination with other neoplasms, especially sarcoma. In its simple 
form it is a lymphoid hyperplasia and is a local manifestation of 
a diathesis. 

Fibromata are met with in the tonsil either as sessile tumors, or 
infiltrations, so to speak, or more commonly, as small pedunculated 
tumors springing from the mucous lining of a crypt. 

Papillomata are very commonly seen on the velum and uvula and 
less frequently on the surface of the tonsil, invariably pedunculated 
and resembling the adjacent mucous membrane in color. 

Angiomata are rare except in combination with, or secondary to, 
other neoplasms. One or two examples of lipoma are on record. 

Tonsilliths, or tonsillar concretions, are now and then met with in 
a distended tonsillar crypt where they may give rise to very little 
reaction, or are productive of symptoms which might be expected 
from a foreign body. Not infrequently they are discovered in an 
attempt to excise an apparently enlarged tonsil. These concretions 
are composed mainly of calcareous material, phosphate and carbon- 
ate of lime and epithelial debris, frequently with a parasitic nucleus, 
the leptothrix buccalis. 

The treatment of a tonsillar calculus consists in its removal fol- 
lowed by thorough curetting of its bed, with excision of redundant 
portions of tonsillar tissue. Small concretions in the lacunae are not 
very uncommon. The largest tonsillith on record weighed 26.8 
grammes (Robertson). It was somewhat egg-shaped, and the most 
remarkable thing about it was that, in spite of its enormous size, its 
existence was not suspected until its expulsion during a violent 
paroxysm of coughing. A deep excavation in the tonsil marked its 
site. 

264 



MALIGNANT DISEASE OF THE TONSIL. 265 

Malignant disease of the tonsil occurs under two forms, epitheli- 
oma and sarcoma. Either of these may be primary in the tonsil, or 
may reach that organ by extension from the tongue or from the 
pharynx. We find several subvarieties of these two forms, the most 
common being the round-celled sarcoma; next the squamous epithe- 
lioma and finally lympho-sarcoma. Others are practically clinical 
curiosities. 

In the early stages of sarcoma there is a decided tendency to 
limitation of the disease by a definite line of demarcation from the 
healthy tissue, or even encapsulation, ulceration being a late phe- 
nomenon. In epithelioma, ulceration is an early occurrence and the 
lymph glands are usually involved at an early stage. As with these 
growths in other situations we find sarcoma in the young as well as 
the old, while epithelioma is met with at, or after, middle life. In 
many cases no cause is discoverable while in others a distinct source 
of irritation, either in occupation or habits, is ascribed as a cause. 
Syphilis may be admitted as an etiological factor while the influence 
of heredity is accepted by many observers. 

The pain in malignant disease, if not more severe, is more lasting 
than that of any other form of tonsillar disease and, in many cases, 
it is intense and extends to the ear of the side affected. Impediment 
to phonation and deglutition is dependent upon the dimensions of 
the tumor, or the degree of ulceration. The color of a sarcoma is 
generally paler than that of adjacent parts and until ulceration takes 
place the tumor is symmetrical in contour. 

An epithelioma is usually warty and irregular. Frequently the 
excrescences which compose it are quite pallid. After the estab- 
lishment of ulceration a thin and very offensive secretion is formed 
and there is a constant desire to clear the fauces. The appearance 
of cachexia is earlier and more pronounced in epithelioma than in 
sarcoma. Not uncommonly a syphilitic taint complicates the 
cancerous lesion and, in many cases, it becomes necessary to 
differentiate the two diseases. In syphilis swallowing may be 
difficult and somewhat painful. In cancer there is marked odyn- 
phagia and spontaneous acute pain is almost continual. Syphilitic 
lesions of the tonsil are usually either superficial in the form of 
mucous patches, or occur later as deep destructive ulcerations, some- 
what resembling cancer. A gummatous infiltration of the tonsil 
before the stage of softening looks more like sarcoma. In cancer 



266 DISEASES OF THE NOSE, THROAT AND EAR. 

there is always a neoplasm which ultimately breaks down. In 
syphilis there is a moderate amount of lymphadenitis which on 
examination is found to be general. In cancer only the neighboring 
lymphatic glands are indurated and they are painful, or sensitive. 
Hemorrhage in syphilis is rare while in cancer it is frequent and 
free. The absence of cachexia in the former and its presence 
in malignant disease at an early stage may be determined. A 
microscopic examination usually settles any question as regards 
epithelioma, but in sarcoma is somewhat less conclusive. In many 
cases the early symptoms simulate so closely those of simple hyper- 
trophy of the tonsil that amygdalotomy may be proposed and in 
several instances it has actually been done under this misapprehen- 
sion. Such an error is excusable, but is not likely to occur if a 
digital examination discloses an unusual degree of induration. 
Moreover, unilateral enlargement of the tonsil should always suggest 
the possibility of syphilis, or a neoplasm. A tentative course of 
iodide of potash assists in removing doubt as to syphilis. 

A most interesting case of tonsillar tumor first reported by Bryson Delavan 
as a tertiary ulceration simulating sarcoma illustrates how the microscope at 
times fails to clear up a doubtful clinical diagnosis. After two months of sore- 
ness and swelling of the tonsil a deep ulcer with sloughy base and everted edges 
formed, the body of the gland being indurated. There was some pain on swal- 
lowing and the cervical glands were slightly enlarged. The mass was removed 
with the cold-wire snare and sections were examined by several pathologists, 
some of whom pronounced it sarcoma while others were in doubt. The slow 
development of the tumor and the presence in the microscopic sections of an 
extraordinary number of endothelial cells led to the adoption of a diagnosis of 
syphilis. Iodide of potash was given continuously. One year later the tumor 
was as large as ever, was quite hard, and was adherent to the pillars of the fauces 
without infiltrating adjacent tissue. It was somewhat nodular but was not ul- 
cerated. A few of the cervical glands were indurated. The neoplasm was 
dissected out under ether by R. P. Lincoln, who placed sections in the hands 
of several experts. They agreed in excluding malignant disease, but were 
divided between syphilis and simple inflammatory hyperplasia. Eighteen 
months later there had been no recurrence. 

In several cases noted by Newman and others malignant degenera- 
tion of an old syphilitic gumma has been observed. 

The prognosis in malignant disease is, of course, extremely un- 
favorable. 

In the early stages the disease may be retarded by removal of the 
primary lesion together with the affected glands. It is hardly ever 



TUBERCULOSIS OF THE PHARYNX. 267 

possible to reach it through the mouth. Extensive incisions in the 
neck with division of the upper jaw for exposure and extirpation 
of infiltrated glands, as well as of the primary lesion, are required. 
A preliminary tracheotomy is not essential. A radical operation of 
this kind is justifiable with a view to prolonging life and in the 
hope that recurrence may take place in a region where less suffer- 
ing may be imposed upon the patient. The round-celled sarcoma, 
or lymphosarcoma is especially virulent and according to David 
Newman "it is a malady in which, even from the onset, little hope 
can be entertained of saving the patient." Early operation in 
epithelioma gives a somewhat better chance, but the chief difficulty, 
as pointed out by Butlin, lies in the intimate relation between the 
pharyngeal structures and the cervical lymphatics, so that dissemi- 
nation of the disease takes place promptly. Yet in several cases 
of the spindle-celled variety of sarcoma the tumor was found to 
be enclosed by a capsule from which it was actually shelled out. 
Electrolysis, cataphoresis, or the injection of toxins after the method 
recommended by W. B. Coley seem to offer some hope of success, 
at least in sarcoma. More than ioo cases treated with the mixed 
toxins of erysipelas and the bacillus prodigiosus are recorded as 
successful. All were sarcoma in some form except six — three 
endothelioma and three epithelioma — and in all but twenty the 
diagnosis was verified by the microscope. These results certainly 
entitle the method to respectful consideration both in inoperable 
cases and as a prophylactic against recurrence after operation. In 
the majority of cases we are dependent upon palliatives for the 
relief of pain. The application of cocaine to the diseased or ulcer- 
ated surface, insufflation of orthoform, and the hypodermic injec- 
tion of morphine give temporary amelioration. 

TUBERCULOSIS OF THE PHARYNX. 

In spite of the fact that the bacillus is supposed to be capable of 
entering the system through intact epithelium and that it is fre- 
quently found in the air tract of perfectly healthy people, authentic 
cases of tuberculosis affecting the structures of the pharynx are very 
few. As a rule, in this situation it is secondary to pulmonary dis- 
ease or coincident with it; or it may occur as a sequel to tuberculous 
disease of the cervical vertebrae. Primary cases have been reported 



268 DISEASES OF THE NOSE, THROAT AND EAR. 

but there is always a suspicion that a deep-seated or limited lesion 
in the lung has escaped detection. In a case of my own a deep 
ulcer involving the right side of the base of the tongue was diagnosed 
as carcinoma and the whole tongue was excised. There were no 
signs of pulmonary disease at the time and none appeared subse- 
quently. 

The diagnosis is often difficult either because of the absence of 
significant appearances in the lesion itself or because of the existence 
of a mixed infection, the condition being masked by certain phenom- 
ena due to syphilis. In a typical case of disseminated miliary tuber- 
culosis the character of the lesion is sufficiently clear; the nibbled, 
irregular margins of the ulcer permit of little chance of confusion 
with the deep, clean-cut ulceration of syphilis. Moreover, a bacterial 
examination will generally discover the bacillus either in the secre- 
tions or the tissue itself. The tubercular deposit may involve 
the tonsil, the velum, or any part of the pharyngeal wall. Associated 
with the local lesion we usually find more or less pronounced 
cervical lymphadenitis. 

The early symptoms are those of subacute inflammation and their 
real character may not be suspected in the absence of physical signs 
in the lung. At the outset considerable swelling is observed, fol- 
lowed by the formation of yellowish spots of miliary tubercle which, 
after a time, soften and form small ulcers, usually round and 
superficial, covered by a grayish secretion and surrounded by pale 
mucous membrane. Thus several independent foci of ulceration 
develop giving the tissues a so-called worm-eaten appearance. Indi- 
cations of an attempt at spontaneous repair are observed at some 
points but the cicatrices are prone to break down. 

Pain is generally pronounced and aggravated by swallowing until 
deglutition becomes impossible, or the patient may complain 
merely of sensations of dryness and heat. The voice is affected 
either by more or less involvement of the larynx or by accumulation 
of secretion the expulsion of which the patient dreads to attempt. 
The breath is fetid. There is a dry congh, or expectoration is 
free if the lungs are involved. The usual general symptoms of 
tuberculosis sooner or later present themselves. 

The prognosis is necessarily bad both because a lesion in this sit- 
uation is indicative of a severe type of disease and because of 
the interference with nutrition owing to dysphagia. 



LUPUS OF THE PHARYNX. 269 

The treatment is that of general tuberculosis and, in addition, 
certain local applications give good results in primary cases and in 
those not complicated by extensive pulmonary or laryngeal disease. 
In any case we are called upon to adopt measures for the relief of 
pain. An ulcerative process favorably located may be treated by 
curetting and lactic acid, followed by insufflation of iodoform and 
orthoform which together seem to produce anesthesia and promote 
cicatrization. The use of pineapple juice as a spray or a gargle is 
recommended by some as a detergent and mild astrigent as well as 
for the relief of pain. Spraying with a solution of suprarenal cap- 
sule is somewhat effective in the mitigation of irritability, and 
in extreme cases the local use of cocaine and of morphine internally 
is required. Suitable climatic conditions and the usual constitutional 
remedies are indicated. 

Odynphagia in this disease as well as in some cases of tuberculo- 
sis of the larynx often demands first attention. The pain in swal- 
lowing is so extreme that the patient finally gives up attempting 
to eat. The natural result is a rapid decline in strength and vitality. 
In the majority of these cases nothing has been found to equal 
orthoform as a local sedative. Cocaine enables the patient to swal- 
low with comparative comfort but is often objectionable on account 
of the paresthesia it excites. An excellent mode of administra- 
tion is in the form of a lozenge containing one quarter of a grain 
of orthoform, one or two to be dissolved in the mouth ten or 
fifteen minutes before food is taken. Thus we are enabled to 
employ one of our most valuable resources, namely hypernutrition, 
in combating the inroads of tuberculosis. 



LUPUS OF THE PHARYNX. 

Lupus of the pharynx in some respects resembles tuberculosis, but 
exhibits several important points of distinction. The pain and con- 
stitutional disturbance met with in the latter are quite absent. The 
evidence that lupus is a modified form of tuberculosis and that most 
patients affected with the former die of tuberculosis does not seem 
to be wholly sufficient. Moreover, the presence of tubercle bacilli in 
a lupoid lesion has not yet been clearly demonstrated. It is very 
slowly progressive and is not attended by severe subjective symp- 
toms. The function of the pharyngeal structures is interfered 



270 DISEASES OF THE NOSE, THROAT AND EAR. 

with if the velum or the epiglottis is involved owing to thickening 
from infiltration, destructive ulceration, or cicatricial bands. The 
affected region presents a granular appearance in the shape of 
small nodules, soft, insensitive, non-vascular, and in color differing 
but slightly from the surrounding mucous membrane. There may 
be considerable destruction of tissue and the resulting deformity 
from cicatrization, if repair takes place, is very marked. 

In many cases the process is mistaken for syphilis but the history 
of the case, the superficial character of the ulceration and its rapid 
cicatrization independent of special treatment, should establish the 
diagnosis. Glandular involvement is rather rare in lupus, whereas 
a general lymphadenitis is almost invariable in syphilis. Tentative 
treatment may be misleading for the reason that strumous condi- 
tions, under which lupus is sometimes classed, are often benefited 
by alterative medication, while some cases of syphilis offer obstinate 
resistance to specific remedies. 

The majority of cases terminate fatally, but some cures are' re- 
corded as a result of thorough ablation'of diseased tissue and cauteri- 
zation. Tonics and careful nutrition are no less important. 

In a case under my observation many years ago in the service of 
Dr. Asch at the New York Eye and Ear Infirmary, the disease in- 
volved the entire velum and thence extended to the larynx. It grad- 
ually yielded with moderate deformity under persistent applications 
of saturated solution of silver nitrate and Fowler's solution inter- 
nally, and later perchloride of iron locally, two drachms to the ounce, 
combined with the internal use of iron and cod-liver oil. In this 
case the duration of the disease, from the beginning of treatment to 
the time when a cure was pronounced, was upward of two years. 

SYPHILIS OF THE PHARYNX. 

Manifestations of syphilis are met with in the pharynx at any 
stage of the disease, either independently or coincident with cuta- 
neous eruption. 

The primary sore, or hard chanrce, has been observed many times 
upon the tonsil and sometimes presents appearances which permit of 
its easy recognition. The first symptom is a sore throat, aggravated 
by pain in swallowing, which does not yield to ordinary treatment. 
The affected tonsil is considerably enlarged and very early the 



SYPHILIS OF THE PHARYNX. 27 1 

nearest lymphatic glands become indurated. The ulcer itself is 
somewhat granular, grayish in color and implanted upon more or less 
induration. Its surface is usually level with the surrounding parts. 
In the course of two to six weeks a confirmatory secondary syphilo- 
derm may be expected. According to Rhodes we must usually wait 
for this episode before venturing on a certain diagnosis. A super- 
ficial ulcer seated upon an indurated tonsil, rebellious to local treat- 
ment and accompanied by enlarged cervical glands is merely sus- 
picious until an eruption appears. Erythema of the fauces in 
syphilis is apt to develop in connection with a roseola of the skin 
and differs from a simple acute erythema in being less intensely red, 
comparatively free from swelling and sensitiveness, and limited by a 
distinct line of demarcation at the junction of the soft with the hard 
palate. The erythema may invade the tonsils and the pharyngeal 
membrane generally. 

The most common and obstinate and most dangerous, because 
highly contagious, lesion of syphilis of the air passages is the 
mucous patch. Although classified as a secondary lesion it may 
be met with early or late in the course of the disease. It is most 
apt to occur in conjunction with a papillary syphiloderm, but is more 
persistent than the cutaneous lesion Mucous patches seldom give 
rise to decided subjective symptoms, although they are slightly 
sensitive to condiments, acids and hot or cold drinks. When the 
patches coalesce and cover a large area they are decidedly painful. 
In its early stages a mucous patch looks like a small opalescent 
erosion of the mucous membrane, resembling a surface that has 
been touched with nitrate of silver. There is seldom any indura- 
tion except in patches of long standing; in the latter case, several 
may coalesce and form a considerable ulcerated surface which 
projects more or less above the surrounding membrane. In the 
folds of mucous membrane it is not uncommon to see them present- 
ing a distinctly fungating appearance resembling condylomata. 

While these patches are very rebellious to treatment in some cases 
and show a persistent tendency to recurrence, in others they disap- 
pear promptly under superficial cauterization. Ordinarily there is 
no extensive or deep destruction of tissue, but when the patch has 
been exposed to prolonged irritation there may be a good deal of 
breaking down, resulting in true ulceration. When this state of 
things has developed, the suffering of the patient is consider- 



272 



DISEASES OF THE XOSE, THROAT AND EAR. 



able even to the degree of interfering with proper nutrition. This 
is especially the case when the soft palate is involved or the parts 
employed in the act of deglutition are affected (Fig. 108). 

Most of the ulcerating processes met with in syphilis are due to a 
breaking down of gummatous infiltration and are presented in 




Fig. 108. — Syphilitic Ulcer of Right Pillar with Perforation of Velum on Left Side. 

(Be Blois.) 

two forms, superficial and deep. This division is purely an 
arbitrary one and the course pursued in each case is the same; 
namely, in the first place, a distinct induration which presently un- 
dergoes softening with rupture of the overlying mucosa and the 
formation of an excavated ulcer of greater or less depth in pro- 
portion to the degree of infiltration. This manifestation of syphilis 
may be met with at almost any part of the pharyngeal wall and is 



SYPHILIS OF THE PHARYNX. 



2 73 



productive of those deforming and disabling cicatrices which are so 
familiar. A gummatous process in the mucous membrane is exceed- 
ingly insidious and extensive damage may be done before the im- 
portance of the condition is appreciated. (Fig. 109). 

One of the most intractable conditions which we are called upon 




Fig. 109. — Extensive Perforation of Velum in Syphilis. (De Blois.) 

to correct is that of adhesion between the velum and the posterior 
pharyngeal wall resulting from this process. 

Recognition of an ulcer due to disintegration of gummy infiltra- 
tion is usually free from difficulty. The edges are sharply cut, 
surrounded by a well defined areola and the surface of the ulcer is 
more or less excavated and covered with purulent secretion and shreds 
of slough. In the early stages, however, before necrosis has taken 
place identification of the condition is less easy and many cases are 
18 



274 DISEASES OF THE NOSE, THROAT AND EAR. 

recorded in which a softening gummy tumor has been mistaken for 
simple abscess and has been uselessly subjected to the knife. 

No lesions in the upper air tract respond more promptly to suitable 
treatment than syphilitic manifestations, except those occurring in 
so-called malignant syphilis or in individuals in depressed general 
health, and in those who persistently neglect treatment or violate 
hygienic laws. The treatment should be in line with that of syphilis 
in general, supplemented by certain local applications in some cases. 
The chancre usually requires no attention beyond the use of an 
antiseptic gargle or, if it is very sensitive, the occasional application 
of a local anesthetic like cocaine. A similar statement applies to 
erythema of the pharynx. 

The mucous patch, on the other hand, requires more careful atten- 
tion on account of its contagiousness and for the additional reason 
that if allowed to persist it is apt to extend over more surface and 
to greater depth. All irritants, in the first place, such as alcohol, 
tobacco and highly seasoned food, should be abandoned. Gargling 
with an alkaline solution, especially after eating, will be found sooth- 
ing and is usually effective. Repair of the patch in refractory cases 
is expedited by careful application to its surface every second 
or third day of the solid stick of nitrate of silver. The gummy 
tumor, before softening has ensued, is usually speedily dissipated 
by rapidly increasing doses of iodide of potassium. When ulcera- 
tion has taken place necrotic tissue must be removed, the surface 
of the ulcer kept clean, and occasionally cauterized with nitrate of 
silver; at the same time the internal treatment being vigorously 
pushed. In many cases the action of the iodide should be aided 
by mercurials, either in the form of inunctions or internally and, 
in many cases, recovery is assisted by the use of tonics. Attention 
to hygiene, diet and exercise is quite as important as drug-giving. 

The contractions which result from syphilitic ulceration are fre- 
quently incurable. The cicatrices are usually characteristic. 
When adhesion of the velum to the pharyngeal wall is complete 
the patient is able to get his supply of air only through the mouth 
and, in consequence, the act of eating is seriously impeded. It 
is very important, therefore, to restore the normal air tract. In 
some cases this is to a certain degree feasible; in others the naso- 
pharyngeal cavity is obliterated by adventitious bands to such an 
extent that its restoration is quite impracticable. The tendency 



NEUROSES OF THE PHARYNX. 275 

to reformation of adhesions after their division is always very marked. 
To obviate this many devices have been proposed such as the passage 
of a strip of lint through the nose which is allowed to fall between 
the velum and the wall of the pharynx. A plate of lead or of gutta- 
percha suspended in the pharynx by threads passed through the 
nares has accomplished the object. In several cases under my own 
care the patient was provided with a set of dilators of various sizes by 
which the opening was kept free; but readhesion or contraction took 
place when systematic dilatation was suspended. When the adhe- 
sions are very thin and involve simply the margin of the velum a 
proposal made by Andrew H. Smith to cauterize the raw surfaces, 
after division, with monochloracetic acid has been successful, 
the slough caused by this acid being retained long enough to allow 
the formation of protecting granulations. Various ingenious 
plastic operations have been designed for removing the adhesions, 
some of which have been partially successful. Several cases oper- 
ated upon by the late J. E. Nichols resulted very favorably. By his 
method a perforation of the velum is made on either side as far 
from the middle line as possible. Through these perforations setons 
are passed and worn for many weeks or until cicatrization around 
them is complete. The perforations are then joined by incisions 
carried from side to side between them, thus releasing the velum. A 
plate of gutta-percha or vulcanite is worn suspended from the nos- 
trils to keep the fresh surfaces apart until repair is complete. Al- 
though by these various methods we succeed in fairly restoring the 
air tract the damage to the structure of the velum is often irreparable. 
It is surprising how difficulty in swallowing and defects of speech 
may be overcome in course of time and by the exercise of care, 
provided there has been no great loss of tissue. In cases of excessive 
destruction of palatal tissue the only resource is the adjustment 
of an obturator, or artificial -palate. 

NEUROSES OF THE PHARYNX. 

Anesthesia is occasionally met with in the pharynx as a result of 
specific disease and of diphtheria. It has been observed in hysteria, 
in epilepsy and in general paralysis of the insane. As a result of 
progressive bulbar paralysis it is a much more serious condition than 
in the other diseases mentioned. It may be induced temporarily by 
morphine or the bromides. 



276 DISEASES OF THE NOSE, THROAT AND EAR. 

Treatment is seldom if ever necessary and in the presence of a 
grave central nerve lesion is unavailing. 

Hyperesthesia of the pharynx occurs in acute inflammations and 
in those addicted to the excessive use of stimulants and tobacco, or 
it may be a manifestation of hysteria. It is frequently a serious 
obstacle to successful examination, of the upper air passages, and 
is sometimes overcome by the administration of bromides, by 
the local use of cocaine, or by sucking of ice. 

Paresthesia, in which abnormal sensations, as burning, pricking, 
or itching, are complained of, is peculiar to hysterical females and 
neurotic subjects. An exciting cause is frequently discovered 
in certain enlarged follicles of the pharynx or the base of the tongue, 
the destruction of which results in cure. When the perverted 
sensation amounts to pain we recognize a distinct neuralgia of 
the pharynx, the treatment of which depends upon its cause but 
which usually yields to local sedative applications. In hay fever 
a very persistent and annoying itching in the pharynx and in the 
roof of the mouth is often present. 

Spasm of the pharyngeal muscles occurs in various conditions 
such as hysteria, epilepsy, and in certain cerebral diseases. Clonic 
spasm, especially of the levator palati muscle, may be seen in con- 
nection with facial spasm or with a general chorea. Spasm of the 
pharyngeal constrictors has been traced in several cases to cerebral 
tumor. Faucial spasm may be symptomatic of an acute inflamma- 
tory condition, or it may occur in the course of hydrophobia. 

Paralysis of the pharynx is very frequently observed as a sequel 
of diphtheria or from disease of a central area in the medulla. It 
is one of the earliest symptoms of progressive bulbar paralysis. In- 
volvement of the soft palate is attended by forcing of food into the 
nasopharynx during attempts at swallowing and when paralysis of 
the glottis coexists fluids and food may invade the larynx and 
trachea. In bulbar paralysis other symptoms characteristic of the 
disease are more prominent and the prognosis is generally fatal. 
When occurring as a sequel of diphtheria or in connection with 
facial paralysis the prognosis is much more favorable and recovery 
takes place without the adoption of any special line of treatment, 
but it may be expedited by the use of tonics internally, strychnia and 
the local application of galvanism. In so-called myopathic paralysis 
a muscle, or group of muscles, is supposed to be impeded in action 



FOREIGN BODIES IN THE PHARYNX. 277 

by infiltration with inflammatory products, the nerve supply not 
being primarily affected. Such conditions are rare but may follow 
simple inflammatory conditions as in cases reported by the author 
and others. 

Foreign bodies in the pharynx are usually sharp-pointed articles, 
such as fish-bones, pins, or sharp spiculae of bone. Objects with 
smooth surfaces pass on, as a rule, into the esophagus or into the 
larynx. Symptoms are often very misleading, as the erosion of the 
surface which it causes generally induces a sensation as though the 
foreign body were still present. A sharp body, such as a needle, 
frequently pierces the tissues and thence migrates to another part. 
It is often a very difficult matter to locate a foreign body in a nervous 
patient or when it has been long in situ and has excited irritability 
and inflammation. 

By the use of the laryngeal mirror, the parts having been anes- 
thetized with cocaine if necessary, the object is discovered perhaps 
imbedded in the follicle of a tonsil or of one of the glands at the 
base of the tongue or lying in the hyoid fossa. Inspection of the 
parts is, with advantage, supplemented by digital examination and 
sometimes extraction may be effected by means of cotton wound 
on a probe, or upon the finger. In most cases the use of the forceps 
will be necessary. If left alone a small object may become encysted 
and do no further damage. On the other hand, hemorrhage may 
follow penetration of a blood-vessel, or sepsis may ensue from the 
development of phlegmonous inflammation. When a large irreg- 
ular body becomes impacted in the lower pharynx its removal 
by external pharyngotomy may be required. The necessity for 
a resort to external operation will disappear with improvement in 
the technic of pharyngoscopy. A most interesting case is described 
by T. H. Halsted in which he removed with a Jackson instrument 
a penny which had been embedded for four and a half years in the 
posterior wall of the esophagus at its lower end. The symptoms 
had been ascribed to a congenital stricture, but the presence of 
a foreign body was definitely located at about one inch from the 
cardiac orifice of the stomach by means of the X-ray. The latter 
diagnostic resource and the clearness with which the parts are il- 
luminated with the light at the distal end of the Jackson tube have 
added greatly to the accuracy and safety of manipulations in these 
regions, (p. 386.) 



THE LARYNX. 

CHAPTER XVII. 

ANATOMY AND PHYSIOLOGY OF THE LARYNX. METHODS OF 
EXAMINATION. 

ANATOMY AND PHYSIOLOGY. 

The larynx, or "voice box," is composed of two large cartilages, 
the thyroid, or shield cartilage, the cricoid, or ring cartilage, and a 
third somewhat smaller, the epiglottis, a leaf-like lid or valve which 
aids in diverting ingesta from the chink of the glottis. In addition 
to these single cartilages there are six smaller ones arranged in pairs, 
the arytenoid, the cornicula laryngis (Santorini) and the cuneiform 
(Wrisberg). All are closely bound together by ligaments, mem- 
branes and muscles. 

The cricoid, the foundation cartilage of the larynx, is attached 
below to the first ring of the trachea and articulates above with the 
thyroid. It is thicker and heavier posteriorly, where it supports the 
arytenoid cartilages, the latter being surmounted by the cartilages 
of Santorini, or cornicula laryngis, and the cartilages of Wrisberg, 
or cuneiform cartilages. The last three are called the cartilages of 
motion, because they are especially concerned in the movements of 
the vocal bands. 

The thyroid cartilage consists of two ate, united in front at an 
angle of 80 to 9c degrees to form the pomum Adami. Each ala is 
nearly square and has extending upward and downward from its 
posterior border the superior and inferior cornua, the former being 
attached to the hyoid bone by the thyrohyoid ligament, the latter 
articulating with a facet on the side of the cricoid cartilage. 

The arytenoid cartilages articulate with facets on the upper border 
of the cricoid, are triangular in shape on cross section and give 
attachment to all the intrinsic muscles of the larynx except the crico- 
thyroid. The anterior angle of each arytenoid is prolonged at its 
junction with the vocal band and is called the vocal process. It is 
plainly visible in the laryngeal mirror. The cornicula laryngis sur- 

278 



ANATOMY OF THE LARYNX. 279 

mount the apices of the arytenoids, projecting backward and inward. 
The cuneiform cartilages are buried in the aryepiglottic folds in 
front of the cornicula. 

The thyroid and cricoid, which consist wholly of hyaline cartilage, 
and the arytenoids, which are hyaline except at their summits, are 
prone to calcify in advanced life. The others, yellow elastic carti- 
lages, show no such tendency. In addition to those mentioned sev- 
eral insignificant sesamoid cartilages are sometimes met with in the 
larynx. They are very inconstant and when present are of no 
importance. 

The cricoid and thyroid cartilages are united in front and at the 
sides by the cricothyroid membrane, and the thyroid is joined above 
to the hyoid bone by means of the thyrohyoid membrane and liga- 
ments. 

The larynx is bound to the first ring of the trachea by the crico- 
tracheal membrane. The posterior wall of the larynx is held in 
position by various muscles and is in relation with the anterior wall 
of the laryngopharynx. 

The epiglottis, a leaf-like plate of yellow elastic cartilage, is at- 
tached to the angle of the thyroid below its median notch. It varies 
much in size and shape, is somewhat depressed and folded laterally 
upon itself during deglutition, and is joined to the base of the tongue 
by three bands known as the median and lateral glosso-epiglottidean 
folds. It is fixed to the hyoid bone by a membrane called the hyo- 
epiglottic ligament; and from its base pass two bands of membrane 
which form the lateral boundaries of the superior aperture of the 
glottis known as the aryteno-epiglottidean folds. 

The thyrohyoid membrane is composed of elastic fibers uniting 
the hyoid bone with the upper margin of the thyroid cartilage and 
is bounded laterally by the thyroid ligaments which pass from 
the superior cornua of the thyroid to the greater cornua of the hyoid. 
This membrane is pierced by the superior laryngeal nerve and 
arteries. 

The cricothyroid membrane is subcutaneous at its middle portion 
and laterally is overlapped by the cricothyroid muscle. It is crossed 
by a small communicating branch between the two superior laryngeal 
arteries, known as the inferior laryngeal or cricothyroid. Two or 
three small vessels penetrate the membrane and supply the mucous 
membrane of the larynx. 



28o. 



DISEASES OF THE NOSE, THROAT AND EAR. 



The lateral portions of the cricothyroid membrane pass upward 
from the inner border of the cricoid and form the inferior thyro- 
arytenoid ligaments, or true vocal bands, extending from the 
vocal process of the arytenoid cartilages to the angle of the thyroid 
cartilage near its center. These bands are covered by the thyro- 
arytenoid and lateral cricoarytenoid muscles. 




Fig. iio. — Muscles of Larynx, Lateral View. (Deaver.) 

a, epiglottis; b, aryepiglottic fold; c, aryepiglottic muscle; d, thyroepiglottic muscle; 
e, thyroid cartilage; /, thyroarytenoid muscle; g, cricothyroid membrane; h, cricoid 
cartilage; i, trachea; j, superior cornu of thyroid cartilage; k, arytenoideus muscle; 
/, muscular process of arytenoid cartilage; m, lateral cricoarytenoid muscle; n, posterior 
cricoarytenoid muscle; o, facet for articulation with thyroid cartilage. 



The superior thyroarytenoid ligaments, ventricular bands, or false 
vocal bands, consist of fibrous tissue extending antero-posteriorly 
just above the true vocal bands. Muscular fibers within their folds 
are described by some anatomists as the superior or external 
thyroarytenoid muscles. They assist the inferior thyroarytenoids 
(Fig. no). 



ANATOMY OF THE LARYNX. 



28l 



The muscles controlling the movements of the laryngeal cartilages 
are divided into two groups, extrinsic and intrinsic. The extrinsic 
are the sternothyroid, the thyrohyoid, the stylo- and palato-pharyn- 
geus and the inferior constrictor of the pharynx. Ot the intrinsic 
muscles the cricothyroid is attached to the front and side of the 
cricoid and to the lower border of the thyroid cartilage. The lower 




Fig. hi. — Muscles of Larynx, Posterior View. (Deaver.) 

a, laryngeal surface of epiglottis; b, muscular process of arytenoid cartilage; c, cricoid 
cartilage; d, trachea; e, aryepiglottic fold; /, aryepiglottic muscle; g, irvtenoideus 
muscle; h, thyroid cartilage; i, posterior crico-arytenoid muscle; j, recurrent Jarvngeal 
nerve. 



fibers pass to the border of the inferior cornua and act by pulling the 
cricoid directly backward while the spreading fibers which form the 
rest of the muscle swing the cricoid upon the cricothyroid joints, pull- 
ing it backward as well as upward. Some anatomists erroneously 
describe the swinging or tilting movement as taking place in the 
thyroid rather than the cricoid, but most authorities agree that the 



282 DISEASES OF THE NOSE, THROAT AND EAR. 

origin and fixed point of the cricothyroid muscle are upon the thy- 
roid cartilage and that therefore the posterior are the movable ends 
of the vocal bands. For this reason Jurasz advocates calling the 
muscle " thyrocricoid" instead of cricothyroid. The practical effect, 
stretching of the vocal bands, is the same in either case. This mus- 
cle is a tensor of the vocal bands (Fig. in). 

The posterior cricoarytenoid muscle arises from the cricoid car- 
tilage and is inserted into the outer angle or muscular process of 
the arytenoid cartilage. Its upper fibers rotate the arytenoid whilst 
the lower fibers pull the whole mass of the arytenoid outward. It 




Fig. 112. — Scheme of Action of Posterior Cricoarytenoid Muscles. 
(Landois and Stirling.) 

is, therefore, a dilator of the glottis, or abductor of the vocal bands 
(Fig. 112). 

The lateral cricoarytenoid muscle springs from the upper border 
of the cricoid between the origin of the cricothyroid and the crico- 
arytenoid articulation, and is inserted into the forepart of the mus- 
cular process of the arytenoid. It rotates the cartilage inward and 
draws it forward, relaxing and approximating the cords. 

The thyroarytenoid muscle arises from the lower two-thirds of 
the inner surface of the thyroid close to its angle and slightly from 
the cricothyroid membrane. It passes outward and backward and 
is inserted into the anterior surface of the arytenoid cartilage and 
to its base c'ose to the attachment of the lateral cricoarytenoid mus- 
cle. The lower and inner portion is parallel with and blends with 



ANATOMY OF THE LARYNX. 



283 



the vocal band. The upper and outer portion is placed immediately 
beneath the mucous membrane and overlies the ventricle. These 
two divisions of the muscle are sometimes known respectively as the 
inferior, or internal, and the superior, or external thyroarytenoids 

(Fig. 113). 

These muscles rotate the arytenoids and draw the vocal bands 
downward and inward and thus approximate them. At the same 
time they relax the vocal bands as a whole. Some fibers attached 
to the free border of the vocal band are said to be capable of making 
tense a portion only of the band, leaving the rest relaxed, thus re- 




Fig. 113. — Scheme of Action of Thyroarytenoid Muscles. (Landois and Stirling.) 



sembling somewhat the stop action of the finger on a violin string. 
They also make the band thinner and wider. 

The arytenoideus muscle consists of transverse fibers passing 
across from one arytenoid cartilage to the other, and attached to 
their posterior surface. Superficially, oblique fibers pass from the 
base of one cartilage to the summit of the opposite cartilage. A few 
of the latter pass under the arytenoepiglottidean fold and side of 
the epiglottis, constituting the epiglottoarytenoideus muscle. This 
muscle approximates and depresses the arytenoid cartilages 
(Fig. 114). 

The thyroepiglottideus muscle, a part of the thyroaxytenoideus, is 
composed of fibers which extend from the thyroid cartilage to the 
arytenoepiglottidean fold and the outer wall of the pharyngeal pouch 
and epiglottis. 

The nerve supply of the larynx is derived from the laryngeal 



284 DISEASES OF THE XOSE, THROAT AND EAR. 

nerves, superior and inferior. The superior has two branches. The 
external is distributed to the cricothyroid muscle and sends a few 
filaments to the mucous membrane of the larynx; it is chiefly a 
motor nerve. The internal branch is larger and is purely sensory. 
It pierces the thyrohyoid membrane and distributes branches to the 
epiglottis and to the mucous membrane of the larynx as far down 
as the true vocal bands. 

The inferior, or recurrent, laryngeal nerve is the motor nerve of 
the larynx. It arises from the vagus at the root of the neck, winds 
from before backward around the arch of the aorta on the left side 




Fig. 114. — Scheme of Action of Arytenoideus Muscle. 
(Landois and Stirling.) 



and around the subclavian on the right, and then ascends between 
the trachea and the esophagus. It enters the larynx immediately 
behind the cricothyroid joint and divides into two branches, an 
anterior to the thyroarytenoideus, the cricoarytenoideus lateralis, 
and muscles of the epiglottis, and posterior branches to the posterior 
cricoarytenoideus and arytenoideus, and communicates with the 
superior laryngeal by slender filaments near the posterior border 
of the thyroid cartilage (Fig. 115). 

The arterial supply is derived from the superior and inferior thy- 
roid, the epiglottis receiving some branches from the dorsalis lin- 
guae from the lingual. 

The aperture of the glottis is triangular in shape, bounded in front 
by the epiglottis, behind by the arytenoid notch, and on either side 



ANATOMY OF THE LARYNX. 



285 



by the arytenoepiglottidean fold. Between these folds and the wings 
of the thyroid on either side is a depression known as the "pyriform 
sinus," or " fossa laryngo-pharyngea". 

The cavity of the larynx is lined by mucous membrane, somewhat 






/■ 




Fig. 115. — Nerves and Arteries of Larynx. (Deaver.) 

a, greater cornu of hyoid bone; b, thyrohyoid ligament; c, thyrohyoid membrane; 
d, superior cornu of thyroid cartilage; e, aryepiglottic muscle;/, arytenoideus muscle, 
g, posterior border of thyroid cartilage; h, posterior cricoarytenoid muscle; /, crico- 
thyroid articulation; j, cartilago tritacea; k, internal laryngeal nerve; I, superior laryn- 
geal artery; m, cricoid cartilage; n, recurrent laryngeal nerve; 0, inferior laryngeal artery . 



thick and red in color except over the true vocal bands where it is 
pale, thin and adherent (Fig. 116). Numerous elastic fibers and 
mucous glands are found in the submucous tissue. The cavity is 
divided into two portions, the supra- and infrarimal, the true vocal 
bands being the line of separation. Immediately above each vocal 



286 



DISEASES OF THE XOSE, THROAT AXD EAR. 



band lies the ventricle of the larynx, bounded above by the ventricular 
band, and externally by the thyroarytenoid muscle. It is lined by 
mucous membrane continuous with that of the larynx and from its 
anterior part, extending upward about one-half inch, is the laryngeal 
pouch, or "sacculus laryngis." Its mucous membrane contains 
many glands which supply secretion for lubricating the vocal cords. 
At its outer side are fibers of the thyroarytenoideus muscle, while on 
its inner side is an extension of muscular fibers of the arytenoepiglot- 
tideus known as Hilton's muscle or the compressor sacculi laryngis. 



Base of Tongue- 



Median Glosso- 
Epiglottlc Fold 



Ventricular Fold 

Vocal Fold 

Piriform Sinus 

Vocal Process 



Pharvnx 




Epiglottis 

Tubercle of Epiglottis 

Ventricle 
Ary-Epiglottic Fold 

Cuneiform Tubercle 

Corniculate Tubercle 
'"Arytaenoid Commissure 



Fig. ii 6. — View of Interior of Larynx as seen during Vocalization. (Morris.) 



The superior, or false vocal cords, or ventricular bands, stand 
further apart than the true vocal bands and between them and the 
arytenoepiglottic folds on either side is a shallow depression known 
as the fossa innominata. Their contour is full and round and they 
are covered by red, moist mucous membrane, while the true vocal 
bands are pearly white or opaline in appearance and present flat- 
tened surfaces as seen from above. On cross-section the latter 
are triangular, and strictly speaking are neither bands nor cords. 
Their average length in the adult is seven lines (14 mm.). 

The rima glottidis, or triangular space between the vocal bands, 
is limited behind by the interarytenoid commissure, and in front by 
the thyroid cartilage. Its dimensions vary in respiration and phona- 
tion. The infrarimal portion becomes almost circular below the 
vocal bands and is continuous with the trachea (Fig. 117). 



PHYSIOLOGY OF THE LARYNX. 



287 



The larynx is spoken of as the organ of voice, and we are apt to 
lose sight of the important part played by other structures in voice 
formation until our attention is drawn to them by some defect in 





I k 




Fig. 117. — Superior Aperture of Larynx and Dorsum of Tongue. (Denver.) 

a, vocal band; b, ventricular band; c, tonsil; d, adenoid tissue at base of tongue: e. 
foramen cecum; /, posterior wall of pharynx; g, corniculum larvngis; //, cuneiform carti- 
lage; i, epiglottis; k, median glosso-epiglottic fold; /, fungiform papillae; m, circum- 
vallate papillae. 



structure or function. The nasal chambers and the accessory sin- 
uses, the lips, the teeth, the tongue, the velum and pillars of the 
fauces, the trachea and lungs, as well as the shape and size of the 



THROAT AND EAR. 

larynx itself, all share in influencing the timbre and the pitch of the 
voice. The larynx is not even essential to audible and articulate 
speech, as has been shown in a famous case of complete laryngec- 
tomy in which the pharynx was entirely shut off from the lower air- 
tract, the patient learning to speak and even sing by sucking in and 
storing air in his pharyngeal pouch (Solis-Cohen). Similar facility 
was acquired by a patient wearing a trachea tube for complete ob- 
struction of the larynx (Czermak) and by one also wearing a tube 
after an attempt at suicide by cutting his throat (Bourguet), The 
old idea that the epiglottis closes the larynx, like the lid of a box, 
during deglutition, has been supplanted by the view that it curls 
laterally in such a way as to direct the food into the pyriform sinuses 
(Carmalt Jones). In cases, in which the epiglottis has been 
absent, destroyed by disease, or removed, its duty has been assumed 
by the ventricular bands, and no impression has been observed, 
either upon swallowing or speech. It is not very movable, the 
larynx rather rising to meet it in the act of deglutition. The 
ventricular bands assist in protecting the larynx against the invasion 
of foreign substances, but are not concerned in normal voice produc- 
tion. It was once thought that in the formation of the falsetto voice 
they pressed down upon the vocal bands in such a way as to limit 
their vibration (Mandl) , but this view is not capable of proof. They 
substitute for the true cords when the function of the latter is abol- 
ished. The vocal bands are not flat, but on cross-section are seen 
to be triangular or prismatic. Their free edges are composed of 
yellow elastic fibers by which their contour is preserved under vary- 
ing degrees of tension. They are lubricated by secretion furnished 
by the mucous glands of the sacculus laryngitis, which opens into the 
ventricle of the larynx, the ventricle of Morgagni. A few mucous 
glands exist on the true cords. They are very numerous on the 
ventricular bands, and on the latter are also found irregular collec- 
tions of lymphoid tissue, the "laryngeal tonsil." The color of the 
vocal bands is pearly white or opaline. They are about one-quarter 
of an inch shorter in the female than in the male, being about three- 
fourths of an inch long in the latter. Vocal sound is caused by 
impact of the expired air upon their free margins. The interesting 
mode of action of the thyroarytenoid muscles, of which the vocal 
bands are considered by some to be the tendinous portion, has 
already been described. The bands move slightly with respiration, 



PHYSIOLOGY OF THE LARYNX. 289 

approaching each other on expiration and separating a little on 
inspiration, unless the latter be forced, when the reverse is true. 

The aid of the extrinsic muscles, especially the sternothyroid, in 
securing efficient action of the intrinsic is essential, in order to fix 
the thyroid cartilage. The cricothyroid and thyroarytenoid muscles 
cannot come into full play without this preliminary fixation. Yet 
the abnormal use of the extrinsic muscles, as well as conscious or 
voluntary contraction of any of the laryngeal muscles, seems to be 
fatal to purity of tone and results in that disagreeable quality which 
is familiar to us as the " throaty" voice. The range of the speaking 
voice is very limited in most people and is modulated by infinite 
gradations. The tax upon the larynx in singing is much greater 
because a wide range is covered, sometimes more than two octaves, 
and moreover the utmost precision in striking the intervals, never 
less than a semitone, must be assured. When we consider the com- 
plicated and delicate mechanism of the larynx we appreciate the 
importance of favorable conditions, atmospheric and other, to the 
preservation and full development of the singing voice. Large 
demands are made upon the organism in general in vocal efforts of 
extraordinary character, hence the importance of maintaining the 
general health at a high standard if the best results are to be attained. 

The hygienic value of exercises in voice culture, regardless of any 
special musical talent, cannot be too highly estimated. The majority 
of people, unaccustomed to athletic or outdoor sports, seldom if ever 
use their lungs to full capacity. The respiratory gymnastics, in- 
volved in well-directed vocal training, undoubtedly have a tendency 
to overcome a predisposition to pulmonary weakness and contribute 
to an improved vitality which enables one more successfully to resist 
disease in general. The local effect of such exercises, under intel- 
ligent guidance, is often marked in disappearance of small collec- 
tions of hyperplasia in the mucous membrane of the air tract, or 
even on the vocal bands themselves, and in correction of a tendency 
to inflammatory outbreaks. The relation of nasal and pharyngeal 
anomalies to functional and ultimately structural derangements of 
the larynx has been already discussed. 

Aphonia, or loss of voice, and dysphonia, or hoarseness, are symp- 
toms of various diseases to be considered. Anything which inter- 
feres with the mobility, or elasticity, of the vocal bands aets as a cause. 
Similar results follow inflammatory, or obstructive, lesions else 
19 



290 DISEASES OF THE NOSE, THROAT AND EAR. 

where in the air tract, the bands themselves remaining unimpaired. 
The causes affecting the vocal bands are divided into inflammatory, 
muscular, arthritic, and neurotic. As an example of the first the 
voice of a laryngitis may be mentioned. In acute laryngitis it is 
entirely lost; in chronic, laryngitis it is whispering, or raucous. In 
rheumatic laryngitis the muscles are crippled, or there is anchylosis 
of the cricoarytenoid joint. In either case approximation of the 
vocal cords is difficult or impossible. Illustrations of neurotic 
aphonia are met with in hysteria, which is purely functional, and in 
disturbed innervation from pressure of an aortic aneurysm on the 
recurrent nerve. 

The vocal bands resemble the reed of a wind instrument only in 
the fact that their margins vibrate under the influence of the passing 
column of air. The character of the voice is infinitely diversified 
by elongation and shortening, widening and narrowing of the 
bands constantly taking place in the production of different tones. 
The extraordinary combination of actions distinguishes the natural 
larynx absolutely from every possible artificial mechanism. When 
we consider how manifold are the elements concerned we begin 
to realize what a complicated process vocalization is and how futile 
must be any attempt to formulate a theory of voice culture univer- 
sally applicable. 

The shape and dimensions of the resonating cavities, a normal con- 
struction and healthy action of all parts of the vocal apparatus, even 
the texture of the tissue themselves, and more than all the musical 
intelligence and temperament of the individual participate in the 
formation of a voice of satisfactory power and pleasing quality. 

METHODS OF EXAMINATION. 

In laryngoscopy, or examination of the larynx, the position of the 
patient, and the source of light are similar to those in examining the 
nose and pharynx. The only additional instrument is a large- 
sized mirror to be introduced into the fauces with its reflecting sur- 
face downward. It is a good plan always to begin examinations 
of the larynx with the tongue at rest in the floor of the mouth; then, 
to depress it by means of a tongue-spatula; and finally, to support 
the protruded tongue between the thumb and finger. The laryngeal 
mirror should be as large as" the fauces will conveniently accommo- 



EXAMINATION OF THE LARYNX. 29 1 

date in order to obtain a complete image. The patient should be 
directed to breathe quietly, to open the mouth without extraordinary 
effort, and care should be taken to avoid violent traction upon the 
tongue as well as dragging it downward upon the lower incisor 
teeth. It is rather more satisfactory for the examiner himself 
to hold the patient's tongue, except in the exercise of certain manip- 
ulations in which both hands are required, the movements of the 
head being thus under better control. 

The introduction of the mirror in some individuals excites gag- 
ging and it is frequently impossible to obtain a satisfactory view 
without the aid of cocaine, or some form of local anesthesia, or care- 
ful preliminary training of the patient. Sometimes it is well to 
direct him to close his eyes during the examination. If gagging 
occurs, panting respirations may overcome the intolerance; or 
a four per cent, solution of cocaine may be sprayed into the fauces. 
It is well to avoid the pharyngeal wall, if possible, but the 
mirror should be introduced boldly, its back against the velum, 
which should be lifted firmly upward. Timidity in this procedure 
frequently is more disastrous than firmness. In introducing the 
mirror it is sometimes annoying to meet with considerable obstruc- 
tion from upward curvation of the dorsum of the tongue which 
is overcome by directing the patient to phonate a long "ah." After 
the mirror has been placed in position, the interior of the larynx 
is brought into view by causing the patient to sing a falsetto "e, " 
or to make the attempt, which is sufficient. In this way the move- 
ments of the cords and the arytenoids may be studied. In some 
instances the peculiar shape of the epiglottis is a source of difficulty. 
Occasionally it drops over the rima glottidis and cuts off the view 
of the cords. In other cases a lateral compression is noticed 
giving the conformation known as the "omega" shaped epiglottis. 
The impediment thus offered may be overcome, if an examination 
is imperative, by dragging the epiglottis upward and forward, after 
cocainizing, by means of a sharp hook or tenaculum. The long 
tongue spatula of Bleyer or Escat is said to be particularly useful 
in examining children. The former has a curved end intended to 
be passed over the epiglottis, the latter has a bifurcated extremity. 
the prongs of which rest in the sinus pyriformis on either side (Fig. 
118). The left index finger makes a very good tongue depressor 
and to children is less terrifying than an instrument. Traction 



292 



DISEASES OF THE NOSE, THROAT AND EAR. 



may be made by hooking it around the hyoid bone. The first 
laryngeal object seen in the mirror is the tip of the epiglottis. We 
then identify the ventricular bands and the prominences of the 
arytenoids and finally the white vocal bands. It should always be 
remembered that the laryngeal image is transposed antero-posteri- 
orly, that is, the parts seen at the upper edge of the mirror while 
apparently most remote are really at the anterior wall of the larynx; 
those at the lower border are most distant and at the posterior 
commissure. The first view, especially in an 
untrained patient and without cocaine, gives us 
the most reliable picture of the laryngeal cavity, 
since prolonged examination excites muscular 
contraction and causes more or less congestion 
which is misleading. It is sometimes possible 
by tilting the mirror to get a view of the entire 
lateral wall and even a glimpse into the 
ventricles, as well as a considerable distance 
down the trachea, and in rare cases the bifur- 
cation is visible. As a rule the anterior wall of 
the larynx is best seen in the ordinary method 
of making the examination. In order to more 
fully expose the posterior wall of the larynx 
and trachea, we sometimes adopt what is 
known as the position of Killian, in which the patient is made 
to stand erect while the examiner is seated, the head of the 
subject being bent forward so that the eye of the observer 
looks upward at an angle. This is found to be useful in 
case of certain lesions at the posterior wall of the larynx. In 
subglottic laryngoscopy, as suggested by Mermod and others, a 
smaller mirror attached at a right angle to the laryngoscope is 
passed into or beyond the cavity of the larynx. The intralaryngeal 
mirror used by Gerber is oval in shape and its angle is governed 
by an ingenious mechanism which permits its introduction in a 
vertical position. The latter observer claims to have thus located 
a hemorrhage of doubtful origin in a varicosity on the under surface 
of a vocal band, while Max Senator detected in a similar situation 
and removed by cauterization a neoplasm which had robbed a well 
known tenor singer of his voice. The application of this method 
must be very limited. The misnamed instrument, the "autoscope" 




Fig. 118. — Escat's 
Tongue Depressor. 



EXAMINATION OF THE LARYNX. 293 

of Kirstein, is intended to give a direct, or "orthoscopies" view 
of the larynx. Its essential part is a long spatula or concave piece 
designed to grasp the base of the tongue on either side of the median 
glossoepiglottic ligament. In the meantime the patient's head is 
extended forcibly in such a way as to bring the anteroposterior axis 
of the mouth in line with the vertical axis of the trachea. At 
the same time firm pressure upon the tongue drags the epiglottis 
forward and upward, and provided the patient is capable of sub- 
mitting to this irksome position, in some cases a very good direct 
view of the larynx is obtained. It is necessary for the patient to be 
seated and the examiner to stand in front of him and a brilliant 
source of light should be provided. It seems to have been shown 
by Mosher that extreme extension may be avoided by rotating the 
head, or placing it in the "left lateral position," as it is called. A 
laryngeal spatula is passed over the epiglottis and by using the 
upper jaw as a fulcrum the larynx may be dragged forward and 
brought into view by the use of a surprisingly small amount of 
force. The original Kirstein's instrument had attached a small 
electric lamp, but the usual methods of reflection serve the purpose. 
This mode of examination is claimed to be especially applicable to 
children and for the removal of foreign bodies — but, with a little 
tact and patience, the ordinary methods usually succeed. 

It is possible to gain additional information in some cases by other 
methods than inspection. External palpation, for instance, shows 
us whether the thyroid is, or is not, symmetrical, whether abnormal 
sensitiveness is present, and it is claimed to be of especial value in 
detecting laryngeal paralysis, which might not otherwise be recog- 
nized, in consequence of the absence of normal vibration on the 
affected side. A certain amount of corroborative evidence may be 
obtained by auscultation of the larynx; and it is a good plan for the 
examiner to educate his ear to the character of the voice, since in 
certain conditions peculiar qualities are more or less characteristic; 
for example, the rough, harsh voice of syphilitic laryngitis, the weak 
whispering voice of tuberculosis, and the metallic voice and espe- 
cially the cough of recurrent paralysis are in some degree distinctive. 
In this connection the observations of Clark and Scripture on "the 
epileptic voice sign" are of interest. In addition we get valuable 
points, especially in cases of laryngeal neoplasm, by the use of the 
probe. We learn, for instance, some facts as regards the mobility 



2Q4 DISEASES OF THE NOSE, THROAT AND EAR. 

and the density of a tumor of the larynx. Above all one should 
never permit one's interest in the examination to prolong the process 
beyond the endurance of the patient, and if local hyperesthesia is so 
great as to prove insurmountable, it is certainly better to postpone 
attempts to get a view until the patient has been rendered manageable 
by the various methods of training elsewhere described. 

GENERAL THERAPEUTICS. 

The fact should never be forgotten that the larynx is only one 
part of the human machine, and that many laryngeal affections are 
aggravated and perpetuated as well as caused, by some systemic dis- 
turbance. One of the first indications in nearly every laryngeal 
lesion is to secure, as far as possible, absolute rest, not only as regards 
actual talking but by the avoidance of functional excitement as in 
the act of laughing, and in violent exercise. The use of tobacco and 
alcohol should be prohibited in acute and in many chronic conditions. 
The digestion must be looked into and a tendency to constipation 
corrected. Cough resulting from disease in the lungs or bronchi, or 
of a reflex character, must be investigated and its cause removed if 
possible. The habit of clearing the upper air passages by the act of 
hawking is a source of irritation, and is usually excited by some 
trouble in the nasal chambers. It is, therefore, important that in all 
cases of laryngeal disease the nose and pharynx should be carefully 
examined and be relieved of anomalies and deformities, although 
the immediate subjective symptoms the latter induce seem to be 
insignificant. 

As to local therapeutics we may medicate the larynx by means of 
powders, inhalations, vapors or sprays. Fumigations are seldom 
resorted to in laryngeal difficulties and the use of lozenges and gargles 
in any form is, of course, futile. Gargling the larynx by the method 
of Guinier has been described, but it is by no means easy of accom- 
plishment and cannot be considered very practical. Insufflations 
in laryngeal disease are limited to ulcerative processes. In some 
forms, as tuberculosis and carcinoma, certain powders seem to be 
beneficial in relieving pain and promoting asepsis. Medicated 
steam and vapors are most grateful in the simpler forms of acute 
inflammation. 

For routine treatment the use of the spray is generally prac- 



GENERAL THERAPEUTICS OF THE LARYNX. 295 

ticable and much more satisfaction is obtained by employing 
the straight tube, the patient being taught to practise deep inhala- 
tions at the moment of application. Used in this way little or no 
resistance or spasm of the larynx is likely to be excited; whereas, a 
blast of air directly upon the vocal bands, even if the solution it con- 
veys be not very irritating, frequently produces distressing or 
alarming spasm. A similar objection applies to the introduction of 
applicators carrying medicaments into the larynx. The latter are 
reserved for inveterate cases of laryngitis in which the sensitiveness 
of the larynx is so obtunded that little or no contraction is excited 
by the presence of a foreign body. The sponge probang and brush 
of the early days of laryngology have been generally discarded. 
The special form of medication to be applied, whether antiseptic, 
astringent, sedative or stimulant, depends upon the particular 
lesion to be treated. These matters, as well as the question of in- 
strumentation, will receive consideration under appropriate sections. 
We sometimes secure good results from external applications, 
either in the line of depletion, as with leeches, counter-irritation 
with iodine or the blister, or in certain acute and subacute conditions, 
Leiter's coil, or a water poultice. Experience with Eiei's hyperemia 
is still too limited to warrant a confident opinion. Reports by 
certain observers, especially in the treatment of tuberculosis of the 
larynx, impress one as being rather extravagant. 



CHAPTER XVIII. 

DISEASES OF THE LARYNX. ANEMIA AND HYPEREMIA. LARYNGEAL 
HEMORRHAGE. ACUTE AND CHRONIC LARYNGITIS. CHORDITIS 
TUBEROSA, OR VOCAL NODULES. CHRONIC SUBGLOTTIC 
LARYNGITIS. ATROPHIC LARYNGITIS. 

ANEMIA OF THE LARYNX. 

Anemia of the larynx is observed in connection with general 
anemia, or as a "pretubercular" condition. In the chronic form of 
tuberculosis the laryngeal mucosa is often distinctly pale, even inde- 
pendently of structural changes. In chlorosis, in neurasthenic 
conditions, and especially in young girls about the age of puberty 
it is often seen. It merits especial attention as a forerunner of 
tuberculosis. 

HYPEREMIA OF THE LARYNX. 

Hyperemia of the larynx results from overuse of the voice, from 
the abuse of alcohol and tobacco, and also from certain occupa- 
tions in which one is exposed to irritating atmosphere, smoke, 
dust, or chemical fumes. It is most marked where the tissues 
are lax, as on the aryepiglottic folds and ventricular bands; on the 
epiglottis and vocal bands it is less pronounced. It is also met 
with in the course of various exanthemata, either antecedent to or 
associated with skin lesions characteristic of these diseases. It is 
often a chronic, so to speak, normal condition in habitual voice-users, 
especially baritones and basses. 

HEMORRHAGE OF THE LARYNX. 

Hemorrhage of the larynx is a rare occurrence and seldom has any 
significance. It is extremely unusual to see a laryngeal hemorrhage 
in tuberculosis, although the sputa may be stained with blood, espe- 
cially after violent attacks of coughing; whereas, in the ulcerative 
stage of carcinoma it is not infrequent. It may result from trauma- 

296 



ACUTE LARYNGITIS. 297 

tism, or from a foreign body, and has been met with in the course 
of syphilis as a consequence of destructive ulceration extending from 
the larynx to the base of the tongue and involving the lingual artery. 
It is seldom of sufficient moment to demand attention. A simple 
astringent spray usually controls it. Some writers recognize a so- 
called " hemorrhagic laryngitis," the main feature of which is the 
formation of scabs composed of coagulated blood adhering espe- 
cially to the vocal bands, rather than a free bleeding. Gottstein 
regards it as a form of laryngitis " sicca," to be referred to later. 

ACUTE LARYNGITIS. 

Inflammation of the larynx may occur at any stage or in either sex. 
It is more often met with in those exposed to severe weather or sud- 
den changes of temperature, and is rather more common in males 
in consequence of their particular occupations. 

The causes of laryngitis are those affecting mucous membranes in 
general. Sudden changes in atmospheric conditions from hot to 
cold, mouth breathing due to nasal stenosis, damp clothing, espe- 
cially in voice-users, functional activity of the larynx in bad air, or by 
a bad method, or to excess, are among the most frequent. 

Predisposing causes are a depressed state of the system and gastro- 
intestinal disturbances. Previous attacks of inflammation are thought 
to establish a proclivity and it is not unreasonable to suppose that the 
mucosa is rendered more vulnerable by preceding disease. 

In the various exanthemata inflammation of the larynx is observed 
which differs in no respect from simple catarrhal laryngitis except 
that, in some varieties, are developed lesions similar to those occur- 
ring upon the skin. In chicken-pox, for example, vesicles are seen 
upon the epiglottis which break and resemble aphthae. In measles, 
diffuse patches or maculae frequently occur. In scarlatina the 
laryngitis is occasionally complicated by the formation of a pseudo- 
membrane and an unusual degree of edema is present especially 
when renal complications arise. In the laryngitis of typhoid fever 
a decubitus ulcer may form, or ulceration involving the lymphoid 
tissue resembling that of Peyer's patches is not infrequently noticed. 
The laryngitis of erysipelas is rare and exceptionally dangerous 
when the phlegmonous type is assumed. 

The pathology of acute laryngitis resembles that of inflammation 



298 DISEASES OF THE NOSE, THROAT AND EAR 

of other parts of the air tract except that the catarrhal product is 
deficient in mucus owing to the relative scarcity of glandular tissue. 
In the first stage, as elsewhere, there is active hyperemia with dry- 
ness, followed by tumefaction of the membrane and serous exudation 
which finally becomes tenacious and turbid from the admixture of 
epithelial cells and leucocytes. In the majority of cases resolution 
takes place and the parts resume their normal appearance without 
change. In other cases the condition lapses into one of chronic in- 
flammation. In some instances erosions of the mucosa take place 
but no true ulcerative process is observed. 

The first symptoms noticed are slight hoarseness, a tendency 
to cough, and subjective sensations of dryness and tickling, some- 
times with a feeling of constriction. The use of the voice is un- 
comfortable and even painful in aggravated cases, or it is com- 
pletely lost early in the attack. In children the swelling of the 
mucous membrane produces more impediment to respiration 
in consequence of the relatively smaller dimensions of the larynx in 
the young but it seldom becomes serious unless complicated by 
edema. There may be slight pyrexia especially in children or 
nervous individuals; and in sleep the breathing is somewhat noisy or 
strident. In the mirror the mucous membrane is seen to be uni- 
formly congested, or injected vessels are identified at various regions. 
Occasionally when the coughing is very violent rupture of small ves- 
sels takes place and the sputum is tinged with blood. The vocal 
bands lose their pearly hue or are concealed by swelling of the 
ventricular bands. 

The treatment should be more active in the case of children than 
in adults, although in the latter a laryngitis should never be neglected, 
owing to its weakening effect upon the membranes and the possi- 
bility of a chronic condition supervening. It should begin with 
a calomel purge, fractional doses, one-tenth of a grain, being given 
every half hour until characteristic effects are produced. The 
patient should be kept in a warm even temperature, given hot drinks 
to promote the action of the skin and forbidden to use his voice. 
If cough is a prominent symptom it should be controlled by the use 
of an opiate, preferably codeine or heroin, and by means of steam 
inhalations. The compound tincture of benzoin in water at the 
boiling point, one drachm to the pint, makes a soothing medicated 
vapor useful in these cases. It is said that dilute nitric acid in doses 



ACUTE LARYNGITIS. 299 

of from ten to fifteen drops every half hour for four or five doses, 
and then at longer intervals for a few hours will enable a singer or 
a public speaker to use his voice provided the remedy be resorted 
to at an early stage. The relief from this measure is only temporary 
and it is, by no means, to be recommended except in cases of 
emergency. Menthol inhalations, or vapors of menthol, applied 
by means of the atomizer or nebulizer, often give relief, the strength 
of menthol being about five grains to the ounce of fluid albolene. 
It is well in using the spray in these acute conditions to employ 
the straight rather than the down tube, the patient being instructed 
to inhale at the moment the spray is formed. It is unwise to use 
too much energy in local treatment. All applications should be 
emollient and protective. 

External applications. of water poultice, flannel wrung out in hot 
water, applied next to the skin and covered with a larger piece of 
oiled silk, known in Germany as the Priessnitz compress, give some 
degree of relief. If the case is seen in the early stage it is sometimes 
possible to abort it by external counter-irritation, depletion by 
means of leeches, or the application of Leiter's ice-water coil. By 
far the most important indication, in cases of acute laryngitis, 
is to enforce absolute rest. The patient should be isolated so far 
as possible, kept in an equable temperature and not allowed to 
use his voice in any way. In the event of the development of 
edema to a threatening degree it is necessary to resort to scarifica- 
tion or puncture of the swollen tissues with Tobold's concealed 
lancet. If relief is not obtained in this way the question of in- 
tubation or tracheotomy is before us. The former, in several cases 
recorded, has given most excellent results, but if the edema is situ- 
ated high in the larynx it may be ineffectual on account of the occlu- 
sion of the upper orifice of the tube by the overhanging tumefaction. 
Or the serous infiltration may extend beyond the lower end of the 
tube. In still other cases it may constitute what has been termed a 
" solid edema," upon which scarification makes no impression. In 
such case relief must be obtained by passage of a catheter through 
the stenosed air tract, as proposed by McEwen, or by a tracheotomy. 
Usually edema affects the vestibule of the larynx where it is within 
reach, but cases have been reported by Semon and by Risch in 
which the process was limited to the vocal bands. An extraordinary 
obstacle was met with by Casselberry in attempting an intubation for 



300 DISEASES OF THE NOSE, THROAT AND EAR. 

edema of the glottis. The jaws were so firmly fixed by spasm of 
the masseter muscles as to render opening of the mouth impossible. 
It is advisable to select a tube rather under the size indicated by the 
age of the patient and in adults it is passed under the guidance 
of a laryngeal mirror. A combination of scarification with intuba- 
tion may be efficacious when the tube is found too short to compress 
all of the swollen area. Efforts to introduce the tube may 
lacerate the tissues and release the effused serum. All the evidence 
seems to show that a trial should be made of these measures before 
resort is had to the more formidable external operation. Fortunately, 
owing to the fact that simple catarrhal inflammation does not 
invade the submucous areolar tissue to any extent, edema as a 
complication of an acute laryngisit is very exceptional. By prop- 
agation from the pharynx, as pointed out by Sestier, it is more 
common, and it is sometimes consecutive to disease involving the 
perichondrium or the cartilages of the larynx. Secondary to 
syphilitic or tuberculous infiltration it is more apt to be a chronic 
than an acute edema and seldom demands attention. Fauvel refers 
to it as being possibly the first symptom of renal disease, yet Macken- 
zie affirms that he once examined 200 cases of Bright's disease 
without discovering a single instance of edema of the larynx. Local 
depletion by means of leeches applied over the larynx externally 
and spraying the fauces and larynx at intervals with a solution of 
suprarenal extract may relieve the turgid structures. In this 
connection the experience of S. Solis-Cohen in a case of asthma in 
which acute edema of the palate, pharynx and epiglottis followed a 
free application of the suprarenal-chloretone solution is of interest. 
A disease of which the laryngeal edema is symptomatic must 
of course receive appropriate treatment. Primary " edematous 
laryngitis" is an exceedingly rare phenomenon. Edema of the 
glottis as a symptom or sequel of disease is not infrequently observed 
and occasionally reaches proportions to excite alarm or involve 
danger. In the convalescent stage of acute laryngitis it may be 
necessary to brace up the relaxed membrances by means of mild 
astringent applications; the one preferred at the present time is a 
10 or 20 grain watery solution of alumnol. Preparations of iron, 
chloride of zinc and nitrate of silver are more distasteful and offer no 
superiority. Within recent years many new silver combinations 
have been offered. Among the most promising is silver vitelline, 



CHRONIC LARYNGITIS. 301 

or argyrol, a proteid containing 30 per cent, of silver. It is very 
soluble, is absolutely free from irritating or caustic properties, and 
possesses great penetrating power owing to the fact that it does not 
precipitate albumen or sodium chloride. Hence we may expect the 
most brilliant results in derangements supposed to be dependent upon 
invasion of the submucous structures by bacterial organisms. 

CHRONIC LARYNGITIS. 

Chronic laryngitis is, as a rule, a sequel of the acute form, or 
inflammation may extend to the larynx from the pharyngeal cavity. 
By far the larger number of cases of chronic laryngitis owe their 
origin primarily to a nasal stenosis or disease in the nasal chambers 
which causes mouth-breathing or some change in the condition of 
the air supplied to the lungs as regards purity, temperature, or 
moisture. The abuse of alcohol and tobacco, exposure to irritating 
vapors in certain occupations, excessive use of the voice, as in open- 
air speakers and street hawkers, are frequent causes. In addition 
derangements of the fauces, such as hypertrophied tonsils or an 
elongated uvula, are predisposing causes. The influence of certain 
diatheses, as gout and rheumatism, should not be overlooked. 
Sooner or later in the condition of chronic laryngitis, a prolifera- 
tion of connective tissue cells takes place resulting in thickening of 
the tissues, this thickening not only involving the epithelial layer but 
the submucosa as well. Structural changes may invade the muscu- 
lar tissues. Involvement of the framework of the larynx is met 
with only in the existence of constitutional trouble, such as syphilis, 
tuberculosis, or malignant disease. Frequently, the pathological 
changes are circumscribed and affect a very limited area of the mu- 
cous membrane, constituting what is known as "singers' nodes" or 
chorditis tuberosa of Ttirck. These developments are most frequent 
at the junction of the anterior with the middle third of the vocal 
bands. Sometimes the node is on the margin and again on the upper 
surface of the band and apparently incorporated with it. In the 
former case if the lesion is unilateral a depression may be seen at a 
corresponding point on the opposite cord. In many cases the lesion 
is bilateral and symmetrical. The cord as a whole is slightly if at 
all altered in appearance, or there is a moderate amount of hyper- 
emia, especially in the immediate neighborhood of the node. A 
similar circumscribed increase in connective tissue elements is 



302 DISEASES OF THE NOSE, THROAT AND EAR. 

sometimes noticed at the posterior commissure, or near the vocal 
processes, where the condition has been termed by Virchow pachy- 
dermia laryngis. 

The symptoms of chronic laryngitis are unmistakable. The voice 
is partially or completely lost. It is apt to break unexpectedly 
and, in all cases, a condition of dysphonia exists and the patient is 
himself conscious of being compelled to make an extra effort to pro- 
duce a tone. After a night's rest there is always an accumulation 
of viscid tenacious secretion, the expulsion of which is accomplished 
by more or less violent cough and, at all times, the patient is dis- 
posed to cough especially in attempting to speak or after the use of 
the voice. Sometimes the voice, even when exceptionally hoarse, 
clears up slightly after a few minutes' use. Patients frequently 
complain of a sensation of constriction or foreign body in the region 
of the larynx. Upon inspection w T ith the mirror we find a congested 
mucous membrane with blood-vessels well defined upon the epiglot- 
tis or in the larynx itself. The tissues at the base of the cords are 
frequently more hyperemic than the margins of the cords them- 
selves; or the margins of the vocal bands are irregularly eroded. 
As a rule, the most marked changes are seen at the posterior wall of 
the larynx. Thickening of tissue occurring at that situation may 
interfere with approximation of the arytenoid cartilages and the 
aphonia is due in part to the obstacle thus offered. Interference 
with the action of the intrinsic muscles of the larynx is mechanical 
and not a true paresis. 

The prognosis depends upon the duration and extent of the inflam- 
matory process; other things being equal, the more prolonged the 
condition the less likelihood of complete restoration of the voice. 
The larynx, once the seat of an aggravated degree af chronic inflam- 
mation, can never produce a tone of original quality and clearness 
even though all inflammatory symptoms have subsided. 

The treatment usually consists, in the first instance, of a reform 
of habits which tend to irritate the larynx, and of possible constitu- 
tional states which induce a tendency to laryngeal hyperemia. 
Attention should be paid to diet and to correction of gastro- 
intestinal derangement. Good hygiene should be secured and, 
in many cases, tonics are indicated. 

Locally, stimulating inhalations of oil of pine, or nascent muriate 
of ammonia are useful, after the surface has been cleansed, if 



CHRONIC LARYNGITIS. 303 

necessary, with alkaline solutions. In all cases attention should be 
paid to the condition of the upper air tract and, before we can hope 
to get satisfactory results in chronic laryngeal inflammation, all nasal 
obstructions and pharyngeal abnormalities should be removed. 

In chronic cases some benefit is derived from astringent sprays, 
as applications of chloride of zinc, 10 to 30 grains to the ounce in 
watery solution, or nitrate of silver, 30 grains to the ounce and up- 
ward. Silver solution should always be used in the larynx with 
great caution unless we know that our patient is tolerant of intra- 
laryngeal applications. It not infrequently happens that violent 
and alarming spasm of the larynx is excited by the introduction 
of even the simplest medicament. It quickly subsides if the patient 
is able to take shallow rapid respirations instead of trying to breathe 
deeply. The use of brushes and swabs in the larynx is much inferior 
to that of the spray. Any intelligent person can be taught to inhale 
gently during the process and thus carry the spray into the laryngeal 
cavity. This method is effective and more agreeable than the intro- 
duction of a cotton wound applicator. The latter finds its place in 
connection with the use of caustic or concentrated solutions, the dif 
fusion of which is to be avoided. Tobacco and alcohol should be 
interdicted and the patient should be warned to exercise great cau- 
tion in the use of the voice. In some cases removal to an equable 
climate must be insisted upon. Of late, much attention has been 
paid to the effect of suitable vocal exercise upon hyperplastic changes 
of the mucous membrane in chronic laryngitis and especially in the 
thickening known as " singers' nodes." A careful study of these 
cases will sometimes teach us whether this mode of handling them 
is likely to be effective. In cases of long standing, when the nodes 
are very dense and extensive, we can hope to accomplish but little. 
In more recent cases it is possible that suitable exercise of the voice 
may be of advantage, the theory being that dispersion of the infiltra- 
tion or hyperplasia is effected by a so-called vocal massage of the 
laryngeal structures. The term used in this sense is certainly a 
misnomer. The spontaneous disappearance of the nodes under abso- 
lute rest is sometimes observed and the question arises whether the 
moderate use of the voice in such vocal exercises as are recom- 
mended is not practically a modified rest. 

The observations of Garel and Bernand fail to confirm the 
opinion of Frankel that the changes resulting in the formation oi 



304 DISEASES OF THE NOSE, THROAT AND EAR. 

these nodes begin in the glandular structures. In some cases they 
proved to be small fibromyxomata; in others the changes were in the 
mucous membrane and chiefly vascular. In their experience the 
nodes sometimes disappear spontaneously, the galvanocautery has 
often been employed with success, but ablation with cutting forceps 
is much to be preferred. From examinations of the tissues com- 
posing the nodes made by Rice, Kanthack, Chiari and other investi- 
gators it seems to be proven that they are not of glandular origin 
but consist mainly of connective tissue and epithelial elements. At- 
tention has been drawn by F. I. Knight to the confusion existing 
between this condition and a diffuse granular inflammation involving 
the whole cord, or trachoma of the vocal cord. As a matter of fact 
there may be few or none of the usual local signs of inflammation. 
The term chorditis is therefore open to criticism; moreover, it is 
more appropriate to refer to these nodes as "vocal" rather than 
" singers' " nodules, since they occur not infrequently in those who 
do not sing. There seems to be no evidence to sustain the suspicion 
of a relationship between vocal nodules and a tuberculous diathesis. 
In reviewing the anatomy of the larynx reference was made to the 
curious distribution of the thyroarytenoid muscle to the margin of 
the vocal band. The interesting question suggests itself whether 
persistent and oft-repeated tugging or strain upon certain fibers may 
not induce a hyperemia or even a minute hemorrhage to develop later 
a vocal nodule. 

It seems to be desirable to distinguish between " trachoma" of the 
vocal cord, a condition of diffuse inflammation resembling a granu- 
lar or follicular pharyngitis and involving the whole extent of the 
band; "pachydermia laryngis," which is a hyperplastic overgrowth 
at the posterior commissure and in the neighborhood of the vocal 
processes; and, finally, "chorditis tuberosa," or vocal nodules, iso- 
lated nodular masses usually seated at the junction of the anterior 
and middle thirds of a vocal band, commonly bilateral, often 
only on one side. However closely allied these conditions may be 
pathologically, their respective clinical pictures are sufficiently in 
contrast to award them separate titles. They equally impede phona- 
tion and are equally resistant to treatment, which should be invari- 
ably preceded by careful elimination of morbid conditions in the 
superior air-tract. 

The surgical treatment of these thickened tissues, as a rule should 



CHRONIC SUBGLOTTIC LARYNGITIS. 305 

be avoided since there is danger that the intralaryngeal manipula- 
tions, essential to the removal of a broad-based sessile overgrowth, 
will do more damage than the hyperplasia itself. If the growth is 
pedunculated, or on the margin of the cord and in a well-trained 
subject it is possible to excise the little tumor with a small cutting 
forceps, or to destroy it with a fine electric cautery point. Capart 
divides the treatment of " singers' nodes" into hygienic, medical 
and operative. Although several instances of spontaneous disap- 
pearance have been recorded, he believes that even prolonged rest 
of the larynx has no beneficial effect except upon an associated 
laryngitis. He condemns local treatment by sprays and insuffla- 
tions of astringents and antiseptics, and especially cauterization 
with nitrate of silver and chromic acid as being either ineffective 
or positively dangerous, in consequence of a tendency for these 
agents to spread and cause violent reaction. In operative treatment 
are included ablation and destruction with the galvanocautery. 
For the former a light and very delicate forceps is advised. The 
galvanocautery is reserved for nodes too small to be grasped with 
forceps. 

At best the management of these cases is very discouraging. In 
most cases the forceps is not available, the use of the cautery demands 
the utmost skill and delicacy and is to be thought of only in trained 
and tolerant subjects, and finally the enforcement of absolute rest, 
while most essential, is almost impossible. 

CHRONIC SUBGLOTTIC LARYNGITIS. 

An inflammatory process sometimes seems to expend itself on the 
under surface of the vocal bands and the adjacent wall of the larynx. 
It often leads to considerable thickening and in the laryngeal mirror 
gives the image referred to by Mackenzie as that of "a second vocal 
cord." The affected region is usually redder than normal and looks 
dense and firm. At first it is uniformly smooth, but in old cases 
may become somewhat irregular and even eroded. It has been de- 
scribed by Gerhardt as a chorditis vocalis inferior, but the process is 
by no means limited to the vocal bands, a considerable area beyond 
them being involved. It is not common in this country. Some 
observers trace it to a constitutional diathesis, scrofula, syphilis. 
or tuberculosis, while others regard it as related to rhinoscleroma. 
The symmetry, color and density of the swellings, obvious to the eye 



:: DISEASES OF THE NOSE, THROAT AND EAR. 

as well as on examination with a probe, differentiate this disease from 
edema and from that rare variety of myxomatous degeneration to 
be described elsewhere. It has been mistaken for eversion of the 
ventricles, a lesion the occurrence of which is denied by many author- 
ities. Its chief title to importance rests on the fact that it may 
embarrass respiration to a degree necessitating an intubation or a 
tracheotomy. Systematic dilatation may be required or the hyper- 
trophied tissues may be reduced by excision or by applications of the 
galvanocautery. In some cases the movements of the vocal bands 
are decidedly interfered with by thickening or by infiltration of the 
muscles by inflammatory products and the voice suffers proportion- 
ately. In others the vocal bands move with normal freedom and 
may quite conceal the hypoglottic swelling during phonation. The 
probable relationship of this affection to a constitutional diathesis 
enforces the importance of internal medication. Iron preparations, 
especially the iodide of iron, are said to be useful. Bosworth warns 
against the administration of iodide of potash, lest an edema add to 
the volume of the obstructing hyperplasia. Yet the cautious use of 
the latter drug seems to be indicated when there exists a suspicion 
of syphilitic taint. Local applications., other than those directed 
toward reducing hyperemia or actual removal of the infiltration 
are worse than useless. 

ATROPHIC LARYNGITIS. 

Pathological changes similar to those occurring in the nose and 
pharynx and resulting in atrophy takes place in the larynx, when 
there is presented the condition known as atrophic laryngitis, or 
laryngitis sicca. Some confusion has arisen from the use of different 
terms to indicate what are probably identical diseases., the blenorrhea 
of Stoerk. the ozena laryngis of Baginski. and so on. according to 
the prominence of a given symptom. As a matter of fact the disease 
is extremely rare and is a sequel of an analogous condition in 
the air tract above, which latter is actually the more important. The 
chief characteristic of atrophic laryngitis is a perversion of secre- 
tion, whereby the mucus having lost a proportion of its water}- ele- 
ments tends to form crusts or scales which adhere firmly to the mem- 
brane. At times these scabs cling so closely that bleeding takes 
place when they are forcibly dislodged. They consist of blood., 
mucus and epithelial debris and have a very fetid odor, which they 



ATROPHIC LARYNGITIS. 307 

impart to the breath. The mucous membrane is eroded and if the 
vocal bands are affected their margins are notched and irregular. 
The crusts may be seen at almost any part of the larynx or extending 
down into the trachea. In a case described by B. Tauber the larynx 
and upper part of the trachea were lined completely by a blackish 
cast of incrusted secretion which had to be removed daily with for- 
ceps. The voice is absent until the desiccated secretion is expelled, 
and the crusts may be so thick as to cause dyspnea. Their presence 
is provocative of violent and often painful paroxysms of coughing. 
In some cases there is more or less concomitant acute or subacute 
catarrhal inflammation, when the membranes are swollen and red, 
while Gottstein describes a chronic form in which the mucosa is 
dirty gray in color. This affection seems to be peculiar to adults and 
is said to be more common in women. It is not infrequently 
seen in those who use alcohol to excess and in syphilitics. Massei 
and others maintain that atrophy in the larynx is a direct extension 
of a similar state in the pharynx, while Bosworth lays great stress 
on the theory that catarrhal processes are limited by anatomical 
boundaries and do not extend by continuity of tissue. In any case 
it is a clinical fact that the morbid process in the larynx is secondary 
to some abnormality, atrophic or other, in the nose or pharynx 
which compels mouth breathing or interferes with suitable purifica- 
tion of inspired air. The presence of certain bacteria in the 
secretions, especially the bacillus fetidus, is looked upon by some as 
an etiological factor, but by most observers as a coincidence or 
consequence. 

The prognosis and treatment resemble those applying to atrophy 
in other situations. If the process is not too far advanced the nor- 
mal function of the affected region may be restored by preliminary 
cleansing of the surface followed by soothing or slightly stimulating 
applications in an oily vehicle. The crusts may be softened with an 
alkaline spray, or may require detachment mechanically. Inhala- 
tion of benzoinated steam is grateful and helps to loosen the secre- 
tions. Kyle highly recommends embrocations of petroleum ex- 
ternally. Internal medication is needed if the general health is poor 
or in the existence of a constitutional dyscrasia. The prolonged use 
of large doses of iodide of potash rather predisposes to atrophy, yet it 
is an indispensable drug in syphilis. At best response to treatment 
is slow, and the nose and pharynx must first be free from disease. 



CHAPTER XIX. 

BENIGN NEOPLASMS OF THE LARYNX. 

A benign tumor of the larynx may be denned as one which shows 
no tendency to general dissemination and does not recur after thor- 
ough removal. The latter part of the definition exempts one 
variety of benign growth, namely, papillomata, which do show 
a disposition to return after extirpation. However, the presump- 
tion is that even with these recurrence is due to failure of complete 
removal, although many cases are on record in which apparently 
thorough resection followed by cauterization through a thyrotomy 
wound has proved ineffectual. 

In the etiology of benign tumors in general any condition or 
circumstance which promotes hyperemia or catarrhal inflammation 
is a predisposing cause. Voice strain, local irritants, and a tendency 
on the part of certain individuals to neoplastic formations, a 
" verrucous diathesis," are included among these causes. How 
far overuse or misuse of the voice should be considered a factor 
is more or less of an open question in view of Morell Mackenzie's 
famous case of papilloma occurring in a deaf mute. The majority 
of cases of laryngeal neoplasm have been met with in the adult and 
in the male sex. There are on record several congenital cases. 

The symptoms include alteration of voice varying with the situa- 
tion of the tumor, cough, more or less interference with breathing, 
especially in children, spasm of the larynx, moderate concomitant 
inflammation in some instances, hyperesthesia amounting in excep- 
tional cases to actual pain, and in some varieties hemorrhage. 
Among rare phenomena associated with certain benign neoplasms 
noted by Fauvel may be mentioned salivation and perversion of the 
sense of taste. Impairment of voice varies from slight hoarseness 
to complete aphonia, and is more pronounced when the vocal bands 
are involved, or when the growth is sessile and small than when 
pedunculated even though voluminous (Czermak) . The respiratory 
disturbance is influenced more by the size of the tumor, although 

308 



BENIGN NEOPLASMS OF THE LARYNX. 309 

paroxysmal dyspnea may occur under excitement, on exertion, or 
when the glottic aperture is still further narrowed by sudden swell- 
ing from catarrhal inflammation. A change in position of a pedun- 
culated growth may have a similar effect. When inspiration is more 
impeded than expiration, the growth is probably above the vocal 
bands (Lewin). An extraordinary subjective symptom, or more 
properly premonition of laryngeal neoplasm, was recently detailed 
to me by a young man with papilloma. He is an amateur short dis- 
tance runner, and after a very keen competition he once noticed a 
feeling of intense heat in the region of the larynx followed by partial 
loss of voice, the former lasting for upward of an hour and the lat- 
ter continuing through the following day. This was repeated after 
several subsequent contests until the partial aphonia became perma- 
nent and he was led to seek relief. 

The tendency to malignant degeneration of benign growths in the 
larynx has been the subject of much controversy. The testimony is 
for the most part in refutation, Felix Semon finding ground from 
extensive statistics he has collected to maintain that it is less marked 
when operation has been done than when the tumors have been let 
alone. It must be admitted that new growths may become modified 
from their original type. For instance, a fibroma may grow more 
vascular and finally appear as a genuine angioma, or may undergo 
fatty degeneration. A case of transformation into myxoma has 
been reported by Masucci. In a recent address Crile includes 
papilloma of the larynx among benign growths predisposing to cancer, 
and the assertion is made by E. A. B abler that malignant changes 
in warts and moles are quite frequent. If this be true of skin 
lesions it may also apply to those of mucous membranes and 
statements like the foregoing are likely to reopen the question for 
further discussion. The verdict has been hitherto that malignant 
degeneration of an innocent laryngeal neoplasm as a result of irri- 
tation or traumatism is not proven. 

The prognosis is good, unless the growth is excessive, or, as 
in the case of some papillomata, shows a propensity to recur, in 
which case the voice is liable to be permanently impaired. Several 
cases of spontaneous detachment and expulsion are on record as in 
one of four congenital cases reported by H. A. Johnson, in which a 
papilloma was expelled during a paroxysm of whooping cough. As 
a rule, the development of the growth is so gradual that ample time is 



3IO DISEASES OF THE NOSE, THROAT AND EAR. 

given for a tracheotomy before indications of dangerous stenosis are 
presented. 

In order of frequency benign tumors of the larynx may be enu- 
merated as follows : papilloma, fibroma, cystoma, myxoma, angioma, 
enchondroma, lipoma, and adenoma. The most frequent by far is 
the first mentioned, papilloma. Papillomata commence in the pap- 
illae of the mucosa, involve the epithelial cells and form wart-like 
growths, called by Virchow pachydermia verrucosa. They are usu- 
ally situated on the vocal bands and at the anterior part of the larynx 
(Fig. 119). They rarely occur elsewhere and almost never at the 





Fig. 119. — Papilloma of Larynx. (Schnitzler.) 

posterior commissure. A form of excrescence resembling papilloma 
occurring in tuberculous laryngitis in the interarytenoid space is not 
entitled to be thus classified. They are frequently more or less 
pedunculated and they usually develop rapidly, especially in chil- 
dren, and, in most cases, occupy the supraglottic region. In many 
cases fungous or cauliflower expansion of the mass of the tumor is 
very apparent. 

Fibroma is a neoplasm of adult life. It is usually sessile and 
single, situated on one or the other vocal band, varying in size from 
that of a millet seed to a hazelnut or, in rare cases, almost filling 
the laryngeal cavity (Fig. 120). Usually it is round, symmetrical 
and redder than the band to which it is attached. A single case 
of fibroma of the larynx has come under my observation, in which 
I removed a growth the size of a small pea from a vocal band with 
Mackenzie's forceps. Growths in this class are spoken of as 
soft fibromata or fibrocellular, when their structure is made up in 
large part of cellular elements. In exceptional cases the tumor 
has been known to reach extraordinary dimensions, as in the 



CYSTOMA OF THE LARYNX. 311 

instance reported by Chappell. A fibroma springing from the left 
aryepiglottic fold projected into and nearly filled the pharynx 
where it had formed several adhesions. It was successfully re- 
moved by subhyoid pharyngotomy, after preliminary tracheotomy, 
and was found to weigh 20 grams and measure 4 1/2 inches in 
circumference. 





a 



Fig. 120. — Fibroma of Larynx on Phonation (a) and During Respiration (6). 

Cystomata have been met with in adult life as late as the sixty- 
fourth year as well as in young children. They occur in the form 
of retention cysts of the muciparous glands at almost any situation, 
the vocal cords included (Fig. 121). The epiglottis' seems to be the 
favorite site (Fig. 122). In a case of cyst of the epiglottis under 
my care several years ago a tumor the size of a hickory nut was 
attached by a long pedicle to the left margin of the epiglottis. That 
organ was dragged downward by the tumor so as to conceal the 




Fig. 121. — Cyst of Larynx. (In gals.) 

interior of the larynx. The tumor itself was not to be seen until 
forced into view by the act of retching. It was easily removed with 
the cold-wire snare. In some cases in which the tumor was small 
and sessile simple incision has been sufficient to effect a cure, as in a 
case described by Payson Clark, in which the tumor, attached to a 
vocal band, could not be seized with forceps. It was therefore in- 



312 



DISEASES OF THE NOSE, THROAT AND EAR. 



cised with a concealed lancet. A little milky fluid escaped, and the 
cyst walls collapsed and shrank away. Four varieties are enumer- 
ated by Emil Glas: i. Retention cysts due to clogging of the duct 
of a lymphatic gland. 2. Congenital cysts resulting from a fault 
in development. 3. Traumatic cysts analogous to those cystic 
tumors of the iris described by Fuchs as following a perforating 
wound. 4. Lymphatic cysts, the rarest variety in which are included 
those due to degeneration of polypoid growths as well as those 
caused by hemorrhagic extravasation. The last mentioned is 
perhaps the more frequent mode of formation. 




Fig. 122. — Cyst of Epiglottis. 



These neoplasms are neither sensitive nor vascular. It is well 
enough to cocainize the parts before removal is attempted, but any 
special precautions against hemorrhage are superfluous. The diag- 
nosis is clear. They are usually pedunculated and elastic and are 
more or less translucent, provided their contents are fluid and 
serous, but not if they contain gelatinous, colloid, or bloody material 
as in certain rare cases (Lefferts). The size of these growths varies. 
They may become so large as to necessitate a tracheotomy or even 
as in one case a pharyngotomy. They may occur at any age. One 
about the size of a hempseed has been found post mortem in a child 
fourteen days old ( Abercrombie) , and one the size of a hazelnut is 
reported to have caused the death of an infant thirty-seven hours 
after birth (Edis). 

Myxoma may occur in two forms, either as a pedunculated tumor 



MYXOMA OF THE LARYNX. 



3 1 3 



generally situated upon a vocal band, or in the form of a sessile dif- 
fuse mass, a sort of myxomatous degeneration. 

A case of diffuse subglottic myxoma came under my observation several years 
since in the person of a woman forty-eight years of age, who had been hoarse 
and annoyed by wheezing respiration for a year or more (Fig. 123). She had 
some cough and was supposed to have asthma. No pulmonary lesion could be 
detected, but with the laryngoscope a mass of finely lobulated tissue could be seen 
extending from the under surface of the vocal bands down into the trachea and 
encroaching upon the air-tube. Portions of this mass were removed with Mac- 
kenzie's cutting forceps until it became evident that the lower limit of the growth 




Fig. 123. — Subglottic Myxoma. (Author's specimen.) 



could not be reached through the mouth. So much relief was given by partial 
removal that treatment was intermitted for more than a year when the patient 
began to have a good deal of dyspnea and stridulous breathing. An external 
operation was then done under cocaine anesthesia, the cricoid and three upper 
rings of the trachea being divided and a large quantity of soft pulpy material 
was removed with the curette and cutting forceps. The tracheal tube was 
worn for three days and at the end of the third week the tracheal opening had 
healed and the patient was discharged from the hospital. Under the micro- 
scope the growth was seen to be made up chiefly of myxomatous tissue. 



314 DISEASES OF THE NOSE, THROAT AND EAR. 

Angiomata, or vascular tumors, are very uncommon. They are 
usually single and incorporated with a vocal band, and frequently 
contain a large proportion of fibrous tissue. They have generally 
been observed in adults and with one exception only on one side of 
the larynx. They vary in color at different times, on some occasions 
being blanched, at other times vivid red in hue. In an interesting 
case reported by A. J. Brady a globular angioma, the size of a cherry, 
was removed from below the vocal bands at the anterior com- 
missure by means of a Heryng's curette. The patient was a boy, 
age not given, who had cough with hoarseness and bloody expectora- 
tion. Repeated attempts to remove the tumor with forceps under 
cocaine failed. No view could be obtained by Kirstein's mode of 
examination. Finally under moderate chloroform anesthesia, the 
laryngeal reflex not being abolished, the mass was removed with the 
curette in two sittings ten days apart, with complete relief of symp- 
toms. Unfortunately the diagnosis does not seem to have been con- 
firmed by the microscope and the loss of blood at the operation was 
surprisingly scanty. Most operators would consider it injudicious 
to undertake the removal of an angioma with cutting instruments, 
and an approach to a tumor of this kind seated below the vocal bands 
by an external operation might be deemed preferable. 

Enchondroma, or more properly ecchondrosis, the latter being the 
appropriate term for homologous tumors composed of cartilage, may 
spring from any of the cartilages of the larynx, is always of slow 
growth and occurs in adult life. It is usually made up of pure hya- 
line cartilage, with a possible admixture of fibrous and even bony tis- 
sue. An ecchondrosis apparently projecting toward the lumen of 
the larynx from the base of the right superior cornu of the thyroid 
was once removed by Asch with a modified Stoerk guillotine. A 
curious feature of the case was that the patient, an amateur vocalist, 
subsequently gained two notes in his upper register. 

According to Gerhardt there were on record in 1896 only ten cases 
of lipoma of the larynx, five of which were removed during life. 
Several cases have since been added to the number. Kyle states that 
the neoplasm shows a disposition to recur suggestive of a possible 
tendency toward malignant degeneration. Bosworth gives the de- 
tails of four cases of lipoma of the larynx as follows. One was 
reported by Holt in a man of eighty years. It was pedunculated, 
upon the rim of the glottis, and had given rise to symptoms for 12 



ENCHONDROMA OF THE LARYNX. 



315 



years. It was drawn into the larynx and caused fatal asphyxia. In 
a second case, reported by Jones, the lipoma, two inches in diameter, 
was removed through the mouth. In a third case, reported by Mac- 
leod, a pharyngotomy for a tumor as large as an orange was followed 
by fatal hemorrhage. Bruns records the case of a woman, twenty- 
five years old, who had a congenital lipoma removed piecemeal with 
the galvanocautery in fifteen sittings. 

The existence of adenoma, which is included in the list, is denied 
by many authorities. F. Massei has reported two cases, but his, as 
well as several described by other observers, are far from being well 




Fig. 124. — Mackenzie's Laryngeal Cutting Forceps. 



authenticated. To the foregoing may be added lymphomaia and 
accessory thyroid tumors, each of them so rare as to be considered 
clinical curiosities. 

The treatment of these cases of benign tumor must be guided by 
the character of the growth and its situation. Unless very extensive 
or excessively vascular the best results are obtained by endolaryngeal 
operation with forceps, except in cases of relapsing papillomata. 
Many operators give preference to instruments like the snap guillo- 
tine of Mathieu, or Dundas Grant's safety forceps, but the instru- 
ment adapted to the majority of cases is that designed by Morell 
Mackenzie, a double curette forceps, one pattern intended to cut 
anteroposteriorly, the other transversely (Fig. 124). One of the 
most convenient forceps, where for any reason Mackenzie's is 



316 



DISEASES OF THE NOSE, THROAT AND EAR. 



found to be difficult of manipulation, is known as the Schroetter- 
Tiirck canula forceps (Fig. 125). Some cases can be handled by the 




Fig. 125. — Schroetter-Tiirck Canula Forceps. 



cold-wire snare. A very crude method, suggested years ago by 
Voltolini, consists in passing a sponge-probang below the cords 
and then quickly withdrawing it in the hope that the growth may 



TREATMENT OF LARYNGEAL GROWTHS. 317 

be caught in its meshes and torn away. It cannot be considered 
a highly surgical procedure. Chemical caustics have been used 
from time to time but the difficulty here as elsewhere is to restrict 
their action to the neoplasm. In at least one case of multiple 
papillomata in which removal had been attempted with the forceps 
and the growth had shown a disposition to prompt recurrence, 
an intubation tube coated with chromic acid was passed and 
allowed to remain in situ for a number of hours; on removal it 
brought with it masses of sloughing neoplasm. Incidentally may 
be mentioned an ingenious application of intubation attributed to 
Lichtwitz. A tube made with a fenestra permits the growth to pro- 
trude into its lumen, where it may be snipped off without risk to 
the wall of the larynx. Bosworth advocates the use of chromic acid 
fused on a probe, or conveyed on a hooded porte-caustique, especially 
to destroy small fragments left by the main operation. Morell 
Mackenzie, who at one time recommended " London paste," finally 
abandoned it because it excited spasm of the glottis and inflammation 
of adjacent mucous membrane. It must be admitted that the use 
of agents of this kind in effective strength is attended by danger. 

The galvanocautery is more precise and manageable and is decid- 
edly more satisfactory in its results. The use of the galvanocautery 
below the epiglottis is objected to by Lennox Browne and other ob- 
servers, but cases in my own experience convince me that it is 
a most valuable agent here as elsewhere under proper precautions. 
No manipulation of any kind should be undertaken without pre- 
liminary training of the patient. Unless the larynx is under good 
control there is great danger that the constrictors may bring in 
contact with the hot electrode or into the grasp of the forceps 
portions of the laryngeal structure which should not be damaged. 
Since the introduction of cocaine endolaryngeal surgery has been 
greatly facilitated, and a good degree of tolerance is established by 
spraying a 10 per cent, solution of cocaine into the larynx and 
pharynx. In using the laryngeal forceps of Mackenzie the following 
method of technic is adopted: The parts are first well sprayed 
with cocaine, a large laryngeal mirror held in the left hand of the 
operator is introduced and the forceps, having been warmed, is 
passed over the epiglottis into the larynx with blades closed. If 
resistance is excited the patient is directed to take gasping respira- 
tions, or to phonate the falsetto "e" and thus the larynx is brought to 



318 DISEASES OF THE NOSE, THROAT AND EAR. 

a higher level. At the same time the spasm relaxes and the neoplasm 
becomes visible. Advantage of this momentary glimpse should be 
taken to open the blades and seize the growth. It sometimes happens 
in cases of multiple papilloma for example, that it is only necessary 
to open and close the blades Avithout actually seeing the growth at 
the moment, when more or less of the neoplastic tissue will be in- 
cluded in their grasp. In the use of Mackenzie's forceps there is 
but little danger of seizing sound tissues provided the instrument 
be kept in the middle line. It is not well to repeat manipulations 
more than two or three times at a sitting, yet the larynx will stand 
a surprising amount of rough handling without special objection. 

To prevent recurrence, certain applications to the larynx are used, 
such as some of the more powerful astringents, or absolute alcohol. 
With the last mentioned agent the author has had more or less 
experience and under proper conditions is disposed to regard it 
with favor. In the case of a middle-aged lady who showed the 
larynx almost filled with papillomata so that on several occasions 
tracheotomy for relief of dyspnea seemed necessary, the tumors 
yielded to a combination of absolute alcohol with the use of the 
Mackenzie forceps, when under the forceps alone the growth would 
recur almost as fast as it could be removed. The extirpation of the 
tumors in this case was completed by T. H. Halsted, who reports 
favorably on the effect of alcohol instillations. The treatment with 
absolute alcohol is accomplished by means of a laryngeal syringe; 
not more than six or eight drops are applied at a time, the applica- 
tion being made every second day and after the use of cocaine. In 
one case, that of a child eight years of age, the alcohol seemed to 
excite an excessive degree of irritation and had to be abandoned. It 
was resumed after the lapse of a few weeks for the reason that no 
endolaryngeal manipulation was feasible without a general anesthetic. 
The first reapplication of the alcohol was followed within twenty- 
four hours by extreme stenosis from swelling which demanded a 
rapid tracheotomy. 

Internal medication cannot be recommended with confidence. 
Improvement has been claimed by some from the use of full doses 
of arsenic, and following the suggestion of Kaposi as applied to 
cutaneous warts others have had good results with Thuja occidentalis . 
Small doses of protiodide or biniodide of mercury are advised 
by Watson Williams in the postoperative treatment and he also 



TREATMENT OF LARYNGEAL GROWTHS. 319 

speaks well of the local use of a 2 to 5 per cent, solution of salicylic 
acid in absolute alcohol, as proposed by Dundas Grant. 

The use of the snare in the larynx is attended with some difficulty 
in adjusting the loop. In the case of cyst of the epiglottis already 
quoted which occupied the laryngeal face of this appendage the 
loop of the snare was readily engaged. Mackenzie's guarded-wheel 
ecraseur, or a similar instrument devised by Stoerk, is more service- 
able than the unguarded snare. 

The question of splitting the thyroid, or of opening the trachea, 
rarely arises except in children, in growths of unusual extent or 
dimensions, or in those which show a tendency to recur. My own 
experience with opening the trachea for removal of benign neoplasm 
is limited to the single case of subglottic myxoma in which I did a 
high tracheotomy. The operation was uneventful and its results 
were satisfactory. 

In many instances spontaneous disappearance of laryngeal growths 
has been observed to follow the functional rest imposed upon the 
larynx by a tracheotomy. Lennox Browne calls attention to the 
danger in very young subjects of damage to the lungs attendant 
upon the sudden inrush through a tracheal opening of a large volume 
of air as compared with that habitually admitted through a larynx 
partially obstructed by neoplasm. If resorption of laryngeal 
growths may be reasonably expected after a tracheotomy, it would 
seem to be more judicious to adopt this alternative rather than expose 
the patient to the risks of endolaryngeal manipulation with its 
uncertain results in the early periods of life. In children, therefore, 
tracheotomy is often the operation of choice. 

In the adult with multiple or very large neoplasms it may be a 
wise precaution to open the trachea before removal of the growth 
through the mouth is attempted. In some cases it is possible to 
reach portions of a tumor from below. The ingenious suggestion 
that tumors may be excised from the vocal bands by means of a fine- 
bladed knife passed through the cricothyroid membrane or through 
the thyroid cartilage at the level of the bands, as done by Rossbach 
in two cases, and guided in the proper direction by the aid of the 
laryngeal mirror held in the usual position, will hardly be regarded 
as generally feasible. 

Kirstein's method ("autoscopy") by which the larynx is brought 
under direct inspection through forced depression of the tongue and 



320 DISEASES OF THE NOSE, THROAT AND EAR. 

extension of the head, is available in some cases. Direct laryngos- 
copy gives a very clear view of the interior of the larynx, yet for 
routine work the older methods will doubtless be retained, straight 
instruments being reserved for manipulations in the lower air tract, 
where the most brilliant results have already been achieved. A 
general anesthetic is advantageous in children, although in most 
adult cases cocaine gives every facility. As a rule, general anesthesia, 
at least to a profound degree, is not to be recommended, or if the 
operator feels compelled to resort to it he should do a preliminary 
tracheotomy or be prepared to open the windpipe at a moment's 
notice. 

Under the most favorable conditions the removal of a laryngeal 
neoplasm through the mouth with a curved or an angular instrument 
is a procedure demanding considerable dexterity. A growth at 
the anterior commissure and especially below the vocal bands is 
not easily reached; its structure may be so dense or its attachment 
so firm as to resist the action of a cutting forceps. At a first expe- 
rience with forceps even in soft papillomata one is astonished at the 
toughness of the new growth and is tempted to relax the hold of 
the instrument in the fear that normal tissues have been seized. 
In the event of failure from inaccessibility of the tumor, as for 
instance when it is concealed beneath a vocal band, or in a ven- 
tricle of the larynx, or from any cause, the propriety of an external 
operation is suggested. Laryngofissure is not to be lightly advised 
both on account of the added risk involved in the operation itself, and 
especially because of the danger of permanent damage to the vocal 
function. Morell Mackenzie's dictum that "an extralaryngeal 
method ought never to be adopted unless there be danger to life from 
suffocation or dysphagia," is probably as true to-day as it was when 
uttered, but does not include a tracheotomy done in the hope of pro- 
moting resorption of the neoplasm. The conclusion of Bruns that 
the chief objection to an external operation lies in the danger of im- 
pairment of vocal function loses a measure of its force when we take 
into account the fact that the neoplasm itself is responsible for a 
large part of the damage. Moreover, in case it becomes necessary 
to split the thyroid in order to gain access to the growth a sufficiently 
accurate readjustment of the parts may be secured provided section 
of the cartilage is not made completely through its upper border. 
A point of far more importance and strongly favoring endolaryngeal 



TREATMENT OF LARYNGEAL GROWTHS. 32 1 

methods is the fact that recurrences have been much more frequent 
after thyrotomy than after the former. 

In comparing the relative merits of intubation, endolaryngeal oper- 
ation, thyrotomy, and tracheotomy enough experience has accumu- 
lated to authorize positive conclusions. Prolonged intubation, 
as pointed out by Wachenheim, is well known to be dangerous. The 
irritation caused by the tube provokes the formation of webs and 
adventitious bands and consequent stenosis. Two postdiphtheritic 
cases in my clinic signalize this danger. In each of these cases 
the larynx was split by Duel and after division of cicatricial bands 
beneath the vocal cords an intubation tube with a retaining arm 
or pin, like that suggested by John Rogers, was inserted. The final 
results were satisfactory, but the sojourn of the tube in these diph- 
theritic cases was even shorter than would be necessary in an average 
case of papilloma, a fact which discredits the feasibility of intuba- 
tion in the latter condition. On the other hand, Robert Levy 
reports the case of a child four years old who wore a tube one hun- 
dred and eleven days almost continuously with the result of dis- 
persing a collection of laryngeal papillomata. 

In adults, and to a less extent in children, endolaryngeal opera- 
tions have been found satisfactory, except in certain cases of 
relapsing papillomata. Ablation may have to be done over and over 
again and the growths are reproduced with amazing rapidity. It is 
said that Bond once operated on a girl of eighteen, who in ten years 
had been relieved of papillomata about every two months. Hovell 
operated under chloroform fourteen times on a boy three and a half 
years old. Stoker records a case of a man of thirty years with the 
unparalleled record of having submitted to 220 operations since seven 
years of age. Fortunately these histories are seldom repeated, and 
in these days with tractable patients and the aid of cocaine very 
different results may be expected. 

As to thyrotomy, in benign neoplasms of the larynx when we read 
of Walker Downie's case of six operations in one year, of Abbe's 
case of four thyrotomies, cauterization and tracheotomy, and of 
Lendon's seventeen thyrotomies in two years followed by stenosis 
and a permanent trachea tube we are quite prepared to pronounce 
sentence of banishment upon this procedure. It is high time 
to discard an operation that is-not only more or less hazardous, but 
gives no assurance of curing the disease for which it is performed. 
21 



322 DISEASES OF THE NOSE, THROAT AND EAR. 

Turning to tracheotomy we find a far more encouraging showing. 
The reports of Hunter Mackenzie, Massei, Garel and many others 
establish the fact that the physiological rest given to the larynx by 
making a tracheal fistula determines a disappearance of laryngeal 
papillomata in from six weeks to five years. This occurrence has 
been observed so often that tracheotomy must be considered the 
classical mode of treating papilloma of the larynx in very young 
children, while in older subjects the tracheal opening permits a 
resort to endolaryngeal manipulations with deliberation and without 
danger. 

In all cases of benign neoplasm in the larynx it is essential to 
pay attention to the condition of the upper air-tract and in every 
instance make sure that the nasal cavities and the nasopharynx 
are free from obstruction. In the opinion of many lymphoid hyper- 
trophy in the latter situation is a very frequent cause of neoplastic 
formation in the larynx. Lennox Browne held this view, while 
Shurly declares that he has never met with a laryngeal papilloma 
in one having at the same time adenoids in the pharyngeal vault. 
It cannot be supposed that nasal, or pharyngeal, diseases are 
the sole cause of laryngeal neoplasms, but on the ground that the 
former increase the susceptibility of the passages below their elimina- 
tion is certainly indicated. 

The after-treatment in these cases of operation for laryngeal neo- 
plasm consists in the adoption of bland and soothing sprays for the 
correction of a catarrhal condition, and the enforcement of absolute 
rest. To prevent recurrence Fauvel advises insufflation of equal 
parts of savine and alum. Astringent sprays are useful and in 
several cases sprays of alumnol have seemed to me particularly effec- 
tive. In case of violent postoperative reaction it is necessary to 
resort to methods used in controlling simple inflammation of the 
larynx as already described. As a matter of fact acute inflammatory 
stenosis following an operation within the larynx is extremely 
unusual, and the less interference during convalescence the better. 



CHAPTER XX. 

MALIGNANT DISEASE OF THE LARYNX. 

SARCOMA OF THE LARYNX. 

Sarcoma of the larynx is an embryonic connective tissue growth, 
and may be met with at almost any period of life. Bosworth has 
collected 47 cases of sarcoma of the larynx, the youngest being nine- 
teen, the oldest 75 years of age. It is therefore not a frequent lesion 
and there is no evidence of heredity. So far as can be determined 
there is no reason to believe that local inflammation exercises any 
predisposing influence. It may remain limited to the larynx for 
a considerable time, and, only after a long period may extend 
beyond the cartilaginous walls to involve the external structures 
and the lymphatic glands. In a case under my own observation 
a trachea tube was worn for two years without marked progress 
of the disease. It usually occurs as a uniformly round tumor which 



gj^ 




Fig. 126. — Sarcoma of Larynx. {Chappell.) 

seldom ulcerates though its surface may become eroded. Occasion- 
ally it is nodular and shows a tendency to extend downward 
into the trachea. In many cases a microscopic examination is 
necessary to determine its character, but it is often difficult to get 
satisfactory sections for the purpose. In more than halt the 
cases the vocal bands themselves were involved; next in order of 
frequency the ventricular bands and, in two cases, the epiglottis 

3 2 3 



324 DISEASES OF THE NOSE, THROAT AND EAR. 

(Fig. 126). Both round- and spindle-celled forms of sarcoma 
have been met with in the larynx, as well as lymphosarcoma, 
fibrosarcoma and myxosarcoma, primarily, or by extension from 
adjacent parts. 

The symptoms depend upon the size and location of the tumor. 
Usually hoarseness, cough and dyspnea are present, but there may 
be no pain. There is seldom any severe hemorrhage but the 
sputum may be tinged with blood. The tendency to generalization 
is very tardy. The cervical glands are rarely involved owing to 
obliteration of the lymphatics by cell proliferation. Cachexia is 
not marked and does not develop until the laryngeal disease has 
existed for a long period. 

The prognosis of sarcoma of the larynx is bad. In the majority 
of cases we are compelled to choose between a tracheotomy for the 
relief of laryngeal stenosis and complete extirpation. The latter 
must be regarded in most cases as merely postponing an inevitably 
fatal result. In a few cases of partial extirpation for very limited 
disease the operation has been successful. The mode of operating 
depends upon the size and situation of the tumor. Out of twenty- 
one cases of operation through the natural passages by the forceps, 
snare or knife collected by Bosworth, six were cured, eight were 
improved, two recurred, four were fatal, and in one there is no 
record of ultimate result. Whatever external operation is under- 
taken it is desirable to do a preliminary tracheotomy. One is often 
disappointed to find on splitting the larynx that the disease is much 
more extensive than it appeared in the mirror, so that what promised 
to be a partial extirpation must be converted into a complete laryn- 
gectomy. 

CARCINOMA OF THE LARYNX. 

For many years the terms sarcoma and carcinoma were used inter- 
changeably to indicate malignant disease. Confusion on this point 
has been largely dispelled by limitation of the term carcinoma to 
epithelial tissue growth. 

Cancer of the larynx may be extrinsic, intrinsic, or both combined. 
Krishaber includes in the first those lesions involving the epiglottis, 
the arytenoids, the aryepiglottic folds and the pyriform sinuses, and 
in the second those springing from the vocal bands, the ventricular 



CANCER OF THE LARYNX. 325 

band, the ventricles and the region of the larynx below the vocal 
bands. 

Among carcinomatous lesions epithelioma largely predominates, 
although cases of medullary cancer and scirrhus have been recorded 
(Fig. 127). Its rarity is evidenced by the fact that in 11,131 cases 
of cancer collected by Gurlt only 63 of the larynx were found. 
Hereditary influence was thought to have been discovered in about 
25 per cent, of the cases, and the disease is frequently traced to 
overuse of the voice. There is usually a history of chronic laryn- 
gitis preceding the development of the neoplasm. It is essentially a 




Fig. 127. — Epithelioma of Right Vocal Band at Anterior Commissure. 
{Schnitzler.) 

disease of middle life and of old age, but one case on record occurring 
in a chlid. It generally involves a vocal band, and until a very 
advanced period of development remains intrinsic. Glandular infil- 
tration in intrinsic disease is rather a late phenomenon, the lymphatics 
in the interior of the larynx not anastomosing directly with those of 
the exterior (Fig. 128). 

The earliest symptom in the majority of cases is impairment of 
voice. It is generally progressive until complete aphonia becomes 
established. Dyspnea is seldom marked at an early stage. The 
characteristic cachexia sometimes develops rather early. The 
patient presents a grayish-yellow complexion, his features become 
shrunken, and he has the appearance of premature old age. The 
glands in the neck sooner or later begin to show signs of infiltration, 
those near the cornua of the hyoid bone being first affected. The 
breath becomes fetid, especially in the event of ulceration, more or 
less expectoration occurs, frequently stained with blood, or profuse 
hemorrhage takes place. Sharp pain, lancinating in character 



326 DISEASES OF THE NOSE, THROAT AND EAR. 

and radiating toward the ear of the affected side is regarded as 
pathognomonic, but is not unknown in other conditions, and is 
often not a prominent symptom in cancer. 

An ulcer of the vocal band in the neighborhood of the vocal 
process surrounded by a livid red areola, and associated with more 
or less thickening and with decided impairment of mobility of the 
corresponding side of the larynx, occurring in a person of middle 
age or older, must be looked upon with suspicion. It is not always 
possible or justifiable to remove a sufficient piece of the ulcer or 




Fig. 128. — Advanced Cancerous Ulceration Left Side of Larynx. 
{Schnitzler.) 

neoplasm for microscopical examination; a superficial section of 
the growth often gives misleading or negative testimony, and the 
manipulations necessary in order to secure a specimen are apt to 
stimulate development. 

It has been a frequent experience to rely upon the microscopical 
diagnosis in doubtful cases and to make all preparations for a radical 
operation, when unexpected amelioration in the local condition took 
place and finally the lesion disappeared altogether. Several years 
ago a middle-aged man came into my service at the Manhattan 
Eye, Ear and Throat Hospital with a clinical history of epithelioma 
of the larynx. He had been under treatment at another hospital, 
where it was reported that the microscope had pronounced the 
lesion to be epithelioma. A preliminary tracheotomy was done 
from which the patient made a good recovery, with the expectation 
of undergoing laryngectomy a week later. In the meantime he 
changed his mind and refused to submit to radical interference. 



CANCER OF THE LARYNX. 



3 2 7 



He left the hospital and was not seen again until a year afterward 
when he returned with voice almost completely restored and with 
hardly a trace of infiltration in the larynx at the site of the supposed 
epithelioma. The case recited is, by no means, an unusual one, and 
illustrates the difficulty in making a positive diagnosis from the 
microscopic examination of a small fragment removed per vias 




Fig. 129. — Krause's Laryngeal Set, 1, 2 and 3; Heryng's Curettes, 4 and 5; Landgraf's 

Curette, 6. 



naturales. One may more readily appreciate this fact when recall- 
ing the various appearances presented by different parts of a complete 
section of a morbid growth. In a recent case of thyrotomv for 
epithelioma of the larynx all the diseased tissue removed was divided 
into two portions and one sent to each of two competent microscopists; 
Their reports were absolutely contradictory. Such an experience 
is no discredit to the microscope, but its negative testimony should 
be accepted with hesitation in the face of positive or even suspicious 
clinical signs. Many authorities rely confidently upon the micro 



328 DISEASES OF THE NOSE, THROAT AND EAR. 

scope and attribute its failure to give definite evidence to the use 
of an inefficient instrument in cutting out a piece. Moritz Schmidt, 
for example, insists that a double curette like that of Landgraf 
(Fig. 129) which cuts out a large thick segment of tissue must be 
used. This observer also calls attention to several rare forms of 
cancer especially difficult of recognition. While it usually appears 
as a well-defined tumor, it may have its origin in the deep tissues 
and give rise to a proliferating or vegetating condition on the surface 
of the mucosa closely resembling papilloma. Again the picture of 
malignant disease seated in the ventricle of Morgagni may simulate 
that of a perichondritis, or a cancerous mass at the posterior wall 
or below the cricoid may involve the recurrent nerve and thus its 
first symptoms are those of laryngeal paralysis. He relies upon 
iodide of potash to exclude syphilis in doubtful cases and lays 
great stress upon the yellowish white color considered pathognomonic 
of a cancerous lesion as well as upon the fact that the latter seldom 
develops primarily at the posterior part of the vocal bands. Felix 
Semon describes a snow-white, sharply pointed lesion, resembling a 
papilloma, but less bulbous and rounded, as "extremely suggestive 
of malignant disease." The same authority gives interesting details 
of a case seen by himself and several other eminent surgeons in which 
the clinical history of cancer was almost unequivocal. A trache- 
otomy preparatory to a complete extirpation disclosed a number of 
apparently infected glands and the major operation was abandoned. 
A year later the patient reappeared still wearing his trachea tube 
but with no trace of glandular infiltration and no laryngeal stenosis. 
It seemed that in the meantime he had been taking Clay's mixture 
of Chian turpentine, a preparation that once had quite a reputation 
as a specific in cancer. Semon attaches no importance to the 
use of this article, but holds the view that the case was really one 
of syphilitic perichondritis and that the glandular swelling was 
purely inflammatory. Iodide of potassium was given without 
result when the case was first seen and unfortunately the glands re- 
moved at the operation were not examined microscopically, so that 
the nature of the lesion remains in more or less doubt. 

The diagnosis of carcinoma of the larynx in its early stage is ex- 
tremely important, since it is only at this period that we may hope 
to do anything in a surgical way. The tumor may be seated at a 
point where a radical operation would certainly include it all. Hence 



CANCER OF THE LARYNX. 329 

if the parts can be exposed in the early period of development we 
may succeed in eradicating the disease. The propriety of attempting 
to exclude certain other diseases by tentative treatment always 
suggests itself. The tuberculin test is of service as regards tubercu- 
losis. In using iodide of potash in order to eliminate syphilis, 
large doses must be given. Amelioration in many ulcerative condi- 
tions occurs at the first administration of this drug, whereas no 
impression whatever is made by it upon that rare form of fibroid 
degeneration sometimes occurring in old syphilis. Moreover 
complications may arise from the coexistence of syphilis or tuberculo- 
sis with cancer. Under such circumstances a syphilitic history or 
the discovery of tubercle bacilli may divert us from the more serious 
lesion. According to modern views the presence of the "spirocheta 
pallida" is unmistakable evidence of syphilis. It is difficult if not 
impossible to demonstrate in the late stages. The skin and oph- 
thalmic tuberculin tests commend themselves by their simplicity, 
but they are not infallible and they are not certainly free from risk. 
Transillumination and the Roentgen ray have been used to demon- 
strate an area of infiltration. The results they give are of but little 
value, since by the time an infiltration has become extensive and 
dense enough to give decided reaction other evidences are sufficiently 
pronounced. 

Treatment may be palliative or radical. In case radical interfer- 
ence is not feasible or be declined, we are compelled to meet the 
various symptoms as they arise. The most distressing symptom 
in the final stages if not at the outset is pain. As a last resort we 
have morphine in some form, either hypodermically or by the mouth, 
but it is well to try first the effect of various local anesthetics. 
Temporary relief is obtained from applications of morphine, 4 
grains, tannin and carbolic acid, each 30 grains, in half an ounce 
each of glycerin and water (Ingals). A solution of carbolic acid, 
1 1/2 dr., tinct. iodine 4 dr., and glycerin 2 dr., has been found 
serviceable in mitigating the pain of an ulcerative lesion in malignant 
disease as well as in syphilis. A considerable degree of comfort 
is given in the early stages by spraying with cocaine in 10 per cent, 
solution, or stronger. Several hours' respite from pain may be 
secured by thorough insufflation with orthoform-new. If applied 
after cocainization a certain quantity is likely to be retained in 
contact with the ulcerated surface. 



330 DISEASES OF THE NOSE, THROAT AND EAR. 

Liegeois reports good results from the internal administration of 
Thuja occidentalism as well as from local application of the same drug. 
In a case of recurrent epithelioma of the larynx, after an operation 
by Kraus, the patient was given Fowler's solution of arsenic. Dur- 
ing this course three pieces of the tumor were coughed up and death 
finally occurred from intercurrent pneumonia five and a half years 
after the tracheotomy, the neoplasm having apparently disappeared. 
The favorable reports of such treatment might be thought to throw 
suspicion upon the diagnosis. Experience with " trypsin," a pan- 
creatic enzyme highly commended by John Beard, of Edinburgh, 
and with Doyen's micrococcus neoformans, on which a somewhat 
favorable report has been made by Spicer and Wright, is still too 
limited to justify a final opinion. One who has much to do with 
malignant disease meets with cases in which the clinical history, 
very likely confirmed by histological evidence, has proved delusive. 
Hence the utmost caution should be exercised in our attitude 
toward the alleged "cancer cures" now and then foisted upon a 
gullible public. If a case of malignant disease recovers we are apt 
to jump at the conclusion that the diagnosis was erroneous, yet there 
is reason to believe that spontaneous resorption of malignant growths 
does in rare instances take place. Conversion of metastatic deposits 
into fibrous tissue, after removal of a primary tumor, has been 
observed, and prolonged quiescence or even retrogression of disease 
after partial operation is not unknown, although an exception to 
the rule. 

The surgical treatment of cancer of the larynx may be conducted 
through the mouth or by external operation. 

The endolaryngeal method is supported by a number of successful 
cases reported by B. Fraenkel. In one case in which a neoplasm 
was extirpated with the galvanocautery loop five recurrences took 
place. In one the cervical glands had to be removed by repeated 
external operations. The importance of constant watchfulness is 
insisted upon, so that the time for an external operation, should it 
prove to be imperative, may not be permitted to pass. Allowance 
must be made for the unusual diagnostic acumen and manual 
dexterity of this operator. Up to the present time about 50 cases 
of endolaryngeal operation by various surgeons have been reported 
showing a record of recurrence in 37 per cent, and of cure in 40 per 
cent. (Sendziak). Successful cases have been reported by Mermod 



CANCER OF THE LARYNX. 33 I 

and Kraus, the latter observer very properly limiting the endolaryn- 
geal operation to polypoid and circumscribed cancers. One of 
the firmest advocates of endolaryngeal extirpation is Jurasz, who 
restricts the method to the first stage when functional disturbance is 
slight and the disease is local and circumscribed. He thinks well of 
the electric cautery, but prefers excision by means of a punch forceps 
of his own design. From a thorough review of this subject Gouguen- 
heim and Lombard- conclude that the endolaryngeal route is not 
available for cancers even of limited extent. They express decided 
preference for partial laryngectomy in operable cases. It would 
be unfortunate if the results first quoted should unduly inspire the 
zeal of surgeons in this direction, lest improper cases be selected for 
endolaryngeal operation and thus valuable time be lost. The 
majority of cases apply for advice so late that relief of symptoms 
by the use of local applications and, if necessary, the introduction 
of the trachea tube, comprise all that we are justified in doing. In 
a small proportion in which an early diagnosis is positive and in 
which the disease is known to be distinctly circumscribed fissure 
of the larynx with thorough removal of the soft parts involved and 
beyond, offers some hope. The objects in view are in the first 
instance to eradicate the disease, and if that is not feasible to add to 
the comfort and prolong the life of the patient. The latter course 
may seem less humane than a well-directed euthanasia, yet public 
sentiment does not permit us to treat the human subject with 
the consideration we apply to the lower animals under similar 
circumstances. Cases in which the disease is progressive and 
has invaded the larynx so far as to necessitate complete removal 
of that organ with its cartilages and the adjacent glands, are not 
good subjects for radical interference. The probability is very 
strong that the disease has by this time crept along some lymphatic 
channel beyond the reach of the eye where it will escape the knife, 
and become a focus for recurrence within a short time. The 
opinion is expressed by Hartley that although the mortality is high 
and permanent cures few total laryngectomy is justifiable. With 
increased accuracy in diagnosis and improvement in operative 
technic the results hitherto far from reassuring may become 
more favorable. Gluck, of Berlin, attributes his exceptional 
success to prevention of aspiration pneumonia by a preliminary 
resection of the trachea, the air-tract being thus absolutely isolated 



332 DISEASES OF THE NOSE, THROAT AND EAR. 

from the site of operation. In view of the fact that the laryngeal 
tissues are enclosed in cartilaginous walls, through which no lym- 
phatics pass, the chances of recurrence after removal of cancer of 
the larynx strictly intrinsic are less than in other situations. There 
is a marked difference between intrinsic and extrinsic cancers 
in the greater tendency of the latter to involve the cartilage as well 
as the lymphatics, a point which has a very serious bearing on 
the prognosis and the mode of operating. Watson Cheyne and 
other authorities regard sepsis as the most important factor in 
•mortality from the operation. A careful observance of all precau- 
tions and a judicious selection of time and method of operating will 
surely reduce the danger from this source. Desirable conditions as 
to the patient are enumerated by Delavan as follows: He should not 
be too old, he should be possessed of good vitality, he should suffer 
from no physical defect that may retard recovery, and his tempera- 
ment, intelligence and surroundings should be favorable to a com- 
fortable existence after operation. The personal equation is perhaps 
too little considered. It is a notorious fact that certain individuals 
go through the most formidable surgical procedures with equanimity 
while others collapse under a comparatively trifling ordeal. To some 
the loss of an important organ with deprivation of vocal function is 
intolerable. Confirmed melancholia and suicidal tendency have 
been known to develop after complete laryngectomy. The various 
artificial devices for supplanting the human larynx, while most 
ingenious and interesting, are poor imitations of the original 
mechanism, and to many would seem impossible. The kind of 
voice cultivated by several subjects whose larynx had been removed 
for cancer in such a way that communication between the lungs and 
the pharynx was entirely closed cannot be considered very satisfac- 
tory. In discussing operative interference in a given case the 
patient should be taken into our confidence and the ultimate 
decision left in part at least to him after a fair presentation of the 
question. 

The rule applied to malignant disease in general should be rigidly 
enforced as regards cancer of the larynx, that is, the extirpation 
should include a wide area of adjacent healthy tissue and every 
suspicious lymph gland and channel. Unfortunately, the average 
American will hardly bring himself to submit to the mutilation 
involved in the application of this principle, especially since even 



CANCER OF THE LARYNX. 333 

thus absolute certainty of immunity cannot be ensured. He will 
prefer rather to accept the comfort afforded by anodynes and a 
tracheotomy, when compelled to face that necessity, and in the 
meantime get what pleasure he may out of life. In an eloquent and 
forceful plea for early naked eye diagnosis of cancer of the larynx 
and complete laryngectomy a distinguished authority, J. N. Mac- 
kenzie, has made the admission that there is no single unequivocal 
laryngoscopic sign of cancer. A conclusion must be reached from 
a study of the congeries of symptoms, local and general, subjective 
and objective. Excision of a piece of suspected tissue for micro- 
scopic purposes, except as a very final resort, is objectionable because 
(1) it opens the way to autoinfection and metastasis, (2) it stimu- 
lates the growth of the cancer, and finally (3) it is often inconclusive, 
misleading, and is sometimes practically impossible. It is not an 
uncommon experience for a laryngeal neoplasm previously benign 
in appearance and clinical history to suddenly undergo absolute 
change of behavior after attempts at removal for curative or diagnos- 
tic purposes. As a general rule growths of the larynx of doubtful 
nature, especially in middle-aged or older persons, should not be 
tampered with unless we are prepared to meet this contingency. It 
is not my purpose to discuss the various methods of performing 
excision of the larynx. Our patients are entitled to all the art and 
skill bestowed by constant familiarity with the details of surgical 
technic. Hence it becomes our duty to secure the counsel and 
assistance of the general surgeon in these cases. It remains the 
business of the specialist to cultivate the utmost proficiency in identi- 
fying the early symptoms of laryngeal cancer before the disease has 
become inoperable. The proposition made several years ago by 
H. T. Butlin to do an explorative laryngofissure in every case of tumor 
of the larynx suspected of malignancy has not met with universal 
favor. Should it be accepted as a justifiable diagnostic resource it 
would seem wise never to undertake it without a distinct understand- 
ing that the operator be authorized to proceed to any extent indicated 
by the character of the neoplasm thus exposed. The opinion is 
expressed by Semon that while it is not free from risk the dangers of 
splitting the thyroid are almost always avoidable. The fact has 
often been noted that the disease is invariably found to be more 
extensive than it appeared to be in the laryngeal mirror. Therefore 
the wisest policy seems to be to place our reliance on other means 



334 DISEASES OF THE NOSE, THROAT AND EAR. 

of diagnosis and resort to a thyrotomy only when we are prepared to 
go to the full length of surgical interference. 

The technic of thyrotomy as perfected by Butlin, Semon 
and others gives a rather favorable showing as regards mortality. 
Yet even in the most skillful hands fatalities occur, and the pre- 
liminary tracheotomy, considered essential, is neither so easy, 
especially when the trachea is entered below the isthmus, nor so 
safe as is often represented. 

In a review of the statistics of thyrotomy by Ernest Waggett, 
based upon the experience of the surgeons just mentioned, the 
superiority of laryngofissure over total extirpation in the three par- 
ticulars of (i) preservation of function, (2) death rate from the 
operation, and (3) exemption from recurrence seems to be clearly 
established. He comments adversely on Mackenzie's demand for 
extensive operation in malignant disease of the larynx both on ac- 
count of the deplorable state in which the patient is left and chiefly 
because it offers no security against recurrence. Sendziak, who has 
investigated this subject most carefully, has tabulated 875 cases oper- 
ated upon by the endolaryngeal method, by thyrotomy, by partial 
and by complete excision. He regards operative interference with 
favor and believes thyrotomy to be by far the safest and most 
promising method. His figures for the last 20 years show 54 per 
cent, of cures by thyrotomy and only 23 per cent, by total laryn- 
gectomy. The value of these statistics is especially doubtful, 
since total extirpation is done only in the last extremity, yet the 
comparative mortality with thyrotomy is much less. 

Many malignant tumors of the larynx develop slowly, as declared 
by Ruault, seven or eight years passing without very pronounced 
change. With this fact in mind and viewing the disappointing re- 
sults of radical intervention, it may be worth while to consider meas- 
ures for controlling the nutrition of the affected region, either by 
such a procedure as ligation of the arteries supplying the larynx after 
the method of Dawbarn, or by the frequent application of agents like 
adrenal extract whose ischemic power is well established. 

It remains to be seen whether phototherapy, which has been tried 
with a promise of success in tuberculosis as well as in superficial 
forms of external cancer, is capable of exerting an influence upon the 
less accessible type of malignant disease as developed in the larynx. 
The remarkable success with radium gained by Abbe in cancers 



CANCER OF THE LARYNX. 335 

nearer the surface of the body has not yet been duplicated in the 
larynx. Some of the cases reported as having been treated with the 
X-ray showed more or less improvement, but unfortunately in some 
the diagnosis was not confirmed by the microscope, and the accuracy 
of a diagnosis based on clinical history is open to question. The 
" fulguration " treatment with high frequency currents (d'Arsonval, 
200,000 to 300,000 volts) following surgical removal of as much as 
possible of the tumor (De Keating-Hart) seems to have been 
moderately successful in superficial cancers but is hardly practicable 
in the larynx. Navratil is responsible for the statement that the 
Roentgen rays when used in the larynx may induce an irritative 
and even dangerous effect on the vagus. Delavan asserts that not 
a single authentic case of cure can be found, but he believes in the 
extraordinary possibilities of the method and that in every case of 
reputed cure sufficient time should be allowed to elapse to prove 
its permanency. It seems fair to conclude that all cases manifestly 
inoperable should be allowed the chance it offers. 



CHAPTER XXI. 

TUBERCULOSIS OF THE LARYNX. 

Tuberculosis may attack the larynx primarily or secondarily; in 
the former case, the process is usually acute; in the latter, chronic. 

Primary tuberculosis of the larynx is believed by some authorities 
to be not very uncommon and is thought to have certain distinguish- 
ing characteristics. According to Bernheim, in the beginning mili- 
ary granulations are seen in the arytenoid region accompanied 
by a general laryngitis of mild grade. Finally ulcers form which 
take on a vegetating or papillomatous character. Tubercle bacilli 
are found in the sputum or in scrapings of the ulcers, sometimes 
only after careful and prolonged search. Twenty-nine cases of 
primary tuberculosis of the larynx have been reported by Aronsohn, 
three of which are authenic, in seven the coincident pulmonary 
lesion was limited and believed to be secondary, while in nineteen 
the diagnosis of primary laryngeal disease was based solely on clini- 
cal signs, which of course cannot be accepted as conclusive. Oppor- 
tunities to verify a diagnosis are rare because death seldom occurs 
until the presence of the disease in other situations is manifest. 
Early identification is obviously important, in order by suitable local 
treatment, diet and hygiene to prevent the disease from becoming 
generalized. Some authorities also recognize a pretubercular or 
prebacillary state in which no positive signs of tuberculosis can be 
discovered either in the lungs or larynx. At this time the larynx is 
free from ulceration and infiltration, but, as pointed out by Ringk, 
may be anemic or hyperemic. The former is usually characteristic 
of a chronic, the latter of an acute process. The propriety of 
adopting this term is doubtful, unless it is intended merely to indicate 
a predisposition or a state of lessened resistance. Weakness of 
the voice amounting at times to partial aphonia, subnormal morn- 
ing temperature with more or less rise the latter part of the day, 
associated with anemia of the larynx or possibly a circumscribed 
hyperemia of one vocal band, should always excite apprehension, 
even though cough may be moderate, sputa scanty, and tubercle 

33 6 



TUBERCULOSIS OF THE LARYNX. 337 

bacilli not found. The depth and limitation of an incipient pul- 
monary lesion may prevent its detection by physical signs. We 
may not be justified in pronouncing such a case one of tuberculosis, 
yet steps should be taken to bring about an improvement in the local 
conditions which will tend to diminish a susceptibility to infection. 
This especially refers to use of the voice and to intimate association 
with others known to be infected. The family history and the 
question of heredity are concerned so far as these factors are capable 
of impairing constitutional vigor and power of resistance. In ac- 
cordance with modern views we are not authorized in condemning 
an individual because his ancestors had tuberculosis. An inherited 
tendency, if such a thing exists, may almost surely be corrected 
under favorable conditions and in a climate which permits continual 
life in the open air. Unfortunately the prescribed treatment and 
regime must often be carried out under most adverse circumstances. 

As to etiology, any condition, local or general, which favors the 
growth of the tubercle bacillus, may invite the disease to the larynx. 
Low vitality combined with the existence of a catarrhal state of 
the mucous membrane affords predisposition. We find laryngeal 
tuberculosis more frequently in the male sex than in the female 
for the reason that the occupations of men expose them more 
generally to the exciting causes. It is most likely to develop between 
the ages of 20 and 30 years. 

Subjects of tuberculous laryngitis are liable to intercurrent attacks 
of simple inflammation, and are prone to exhibit temporary improve- 
ment in summer, in mild weather and under change of climate. The 
frequency of the disease is very startling. Heinze, of Leipsic, reports 
4,486 autopsies, in 1,226 of which tuberculosis was found; of the 
latter 51.3 per cent, showed laryngeal lesions, more than one-half 
being ulcerative, a proportion confirmed by the statistics of the 
Brompton Consumption Hospital but nearly twice as large as that 
admitted by many investigators. The mode of invasion of the larynx 
is either by direct infection through the inspired air, by the expec- 
torated sputum, or indirectly by conveyance of bacilli from t uberculous 
foci in the lungs through the blood current or the lymph channels. 
Various theories have been propounded to explain the comparative 
immunity of the larynx. It is said that the bacillus of Koch, which 
is supposed to be the essential element in infection, requires not 
only suitable soil but a quiet resting place for its development, and 



] ] 3 DISEASES OF THE NOSE. THROAT AND EAR. 

that abrasions of the mucous membrane of the larynx, which might 
permit the entrance of the bacillus, are promptly protected against 
it by the formation of exudate or granulations. E. L. Shurly. who 
expresses skepticism as to the importance of the part played by 
bacilli in infection,, combats the foregoing views and calls attention 
to the fact that while some pans of the larynx are almost neyer at 
rest the ventricles are certainly sufficiently quiescent and secluded 
as regions for the lodgment and cultiyation of germs. There is no 
reason to belieye that the laryngeal mucosa diners from similar 
tissue elsewhere in its defensive power. As to the bacillus, while it 
has been proved to retain its vitality in a bronchial gland in a state 
of latency for twenty years, it has also been demonstrated that some 
tuberculous lesions contain no bacilli. The majority of observers 
will probably agree with Delafield and Prudden that the effect of the 
bacilli is governed by their number and virulence, by the nature of 
the tissue in or upon which they rest,, and by the vulnerability of 
the individual. Although some authorities deny that mouth breath- 
ing is a factor in infection, it is believed that the importance 
of nasal stenosis as favoring derangements of any kind in the lower 
air tract should not be underestimated. Yet it must be considered 
injudicious to undertake operative measures for the correction of 
nasal atresia in a tuberculous subject unless it is quite certain that 
his vitality is capable of withstanding the additional drain. 

The pathological changes characteristic of laryngeal tuberculosis 
consist of cellular infiltration and edematous phenomena, together 
with tubercle bacilli, especially in the miliar}' form associated with 
ulceration or caseation. In the early stage the capillaries are en- 
gorged, the tissues are crowded with leucocytes and small round 
cells, the glands are distended with serum and cells and finally 
become obliterated. Xodules of granulation tissue appear, and 
feeble attempts at organization are seen, but finally necrosis, soften- 
ing and ulceration take place. The breaking down process begins 
in the deeper layers, thence extending to the surface of the mucous 
membrane,, or to the perichondrium, in the latter case sometimes 
involving the cartilage itself. Tuberculous foci are identical with 
those found in other situations, consisting of scattered masses of 
large epithelioid cells, usually enclosing one or more giant cells, 
embedded in a zone of granulation tissue and surrounded by loose 
irregular small cells of infiltration tissue. In localized disease a 



TUBERCULOSIS OF THE LARYNX. 339 

compact wall of cells and fibrous connective tissue surrounds the 
morbid deposit. The tubercle is not vascular and bacilli may be 
found both within and without the cells. The secretion of a tubercu- 
lous ulcer is found to contain disintegrated epithelial cells, mucus, a 
small amount of pus, and generally tubercle bacilli. Free pus 
formation is not a usual feature. 

The early symptoms of laryngeal tuberculosis relate chiefly to 
the voice. There is more or less huskiness, the voice becomes low 
pitched, and attempts at loud phonation may result in diphonia, or 
double voice. The impediment to breathing is not, at the onset, at 
all marked, although respiration may be labored and more or less 
stridulous. The amount of sputa is not excessive until the lungs 
become involved to a considerable extent. There is little or no 
trouble in swallowing until the late stages of the disease when deglu- 
tition may become not only difficult but painful. The impediment to 
swallowing is due either to simple inflammatory swelling espe- 
cially of the posterior laryngeal wall, to involvement of the peri- 
chondrium or cartilages themselves, or to more or less extensive ulcer- 
ation. In the early stages there is little or no pain, although the 
patient complains of a sensation as of a foreign body, or simply 
a feeling of uneasiness or dryness. There is more or less exter- 
nal tenderness on pressure over the thyroid cartilage. One of the 
most distressing and persistent symptoms even at the beginning is 
cough. The cough of laryngeal tuberculosis is most marked in the 
morning and when the patient first assumes the recumbent position 
at night. 

The diagnosis of laryngeal tuberculosis in typical cases is free from 
difficulty. There is hardly any laryngeal disease, however, which 
presents so many variations from what we are accustomed to call the 
typical form. In the early stages of the disease, a feature by no 
means invariable, which strikes us with most force in the laryngeal 

' J o 

mirror, is the pallor, of the mucous membrane. This is especially 
marked in the chronic form and is not proportionate to the degree 
of general anemia. Infiltration and tumefaction are observed 
particularly in the interarytenoid space and of the ary-epiglottic folds. 
The normal prominences of the arytenoids are effaced by a pyriform 
swelling involving both sides of the larynx and usually quite sym- 
metrical. They assume the so-called "club-shaped" contour (Fig. 
130). The epiglottis may be infiltrated and swollen, or "turban- 



34o 



DISEASES OF THE NOSE, THROAT AND EAR. 



shaped." In exceptional cases the infiltration of the larynx is 
unilateral, and thus the uncertainty of diagnosis is much increased 
(Fig. 131). The mucous membrane has an edematous, soggy look. 
The movements of the arytenoids are interfered with by infiltration 




Fig. 130.- 



-Tuberculosis of Larynx. Clubbing of Arytenoids and Papillary Excres- 
cences at Posterior Commissure. (Schnitzler.) 



of the muscles or possibly by an inflamed cricoarytenoid joint. The 
importance of the latter has been especially insisted upon by W. 
Fowler, who in upward of fifty autopsies found implication and 
more or less disorganization of the joint in every instance. Aphonia 
is due to this cause, or simply to a general weakness of the intrinsic 




Fig. 



I 3 I - 



-Tuberculous Ulcer with Extreme Swelling of Left Arytenoid. 
{Lennox Browne.) 



muscles of the larynx, or to an intercurrent laryngitis. When there 
is apparent unilateral paresis it is generally observed upon the right 
side and is due to involvement of the right recurrent nerve by 
pleuritic adhesions, consolidation of the right apex, or pressure from 



TUBERCULOSIS OF THE LARYNX. 341 

bronchial glands. Ulceration is met with in late stages and is due 
to a breaking down of small tuberculous foci which coalesce, giving 
the ulcer a characteristic worm-eaten or nibbled margin (Fig. 132). 
Superficial erosions resembling aphthae may occur. Necrosis and 
caries are not uncommon and may involve almost any of the 




Fig. 132. — Tuberculosis of Larynx in Ulcerative Stage. 

{Lennox Browne.) 

cartilages. Among the unusual forms of tuberculous development 
within the larynx are what have been designated granulomata, 
papillary excrescences at the posterior commissure, and distinct 
tumors or nodules, usually rounded and smooth and covered by 
mucous membrane not differing from that of other parts of the 
larynx (Fig. 133). These tumors sometimes soften and ulcerate, 




Fig. 133. — Tuberculous Tumor of Larynx. {Rice.) 

and are most frequently seen on the lateral wall of the larynx, or in 
the trachea. They have been carefully studied by J. N. Mackenzie, 
who was the first to describe a genuine tuberculous tumor of the 
trachea, consisting of miliary tubercles embedded in a vascular 
network of connective tissue. Wart-like growths between the 
arytenoids are occasionally seen in syphilis and in chronic laryngitis. 



342 DISEASES OF THE NOSE, THROAT AND EAR. 

but point to incipient tuberculosis when associated with pallor of 
the mucous membrane or suspicious pulmonary signs. Granular 
hyperplasias at times reach a considerable volume, especially when 
springing from the margins or base of an extensive ulceration. They 
usually shrink before offering any serious impediment to breathing. 
The contrary was true in a case once reported by the author, that of 
a boy twelve years old, in whom laryngeal stenosis from tuberculous 
granulomata demanded an intubation and finally a tracheotomy, 
death occurring a few weeks later from general tuberculosis. , The 
youth of this patient and the presumption that it is an instance of 
primary laryngeal tuberculosis give the case especial interest (Fig. 
134). 




Fig. 134. — Tuberculous Ulceration at Posterior Commissure and Vocal Processes. 

(Schnitzler.) 



The symptoms of general tuberculosis, anorexia, emaciation, hec- 
tic, rapid pulse, night sweats, cough with expectoration, and possibly 
hemoptysis are marked in proportion to the degree and activity of 
pulmonary involvement. Nutrition may be interfered with by a very 
extensive laryngeal lesion before signs of pulmonary disease are in 
evidence. 

A differential diagnosis must be made from cancer and syphilis. 
Confusion is not likely to arise from other sources. In cancer 
there is sooner or later marked cachexia, more or less constant pain, 
frequently shooting toward the ear of the affected side, aggravated 
by swallowing and more intense when fluids are taken. The lesion 
itself begins as a neoplasm, later becoming a deep, ragged ulcer coated 
with grumous, fetid secretion and surrounded by a livid or purplish 
areola. The mobility of that side of the larynx affected is impaired 



TUBERCULOSIS OF THE LARYNX. 343 

early by the infiltration. The voice is lost and stenosis may be ex- 
treme. In syphilis the voice is hoarse and low-pitched, but complete 
aphonia is rare until late destructive ulceration or cicatricial contrac- 
tion occurs. The latter condition may also cause excessive dyspnea. 
The ulcer itself is comparatively free from pain, and the constitu- 
tional symptoms are, as a rule, unmistakable. The lesion is usually 
clean cut with raised indurated edges and covered with necrotic 
detritus. Characteristic scars in the pharynx or elsewhere, or traces 
of the disease at some other part of the body, even in the absence of 
a history, or of active symptoms, will usually solve the problem. The 
greatest perplexity arises in connection with latent syphilis, or " syph- 
ilis ignore," and in cases of mixed infection. An example of the 
latter in my own experience was betrayed by typical ulceration of 
the fauces which healed under mixed treatment leaving characteristic 
scars. The patient had already been sent to a mild climate for tuber- 
culosis, the latter diagnosis having been based on pulmonary and 
general symptoms confirmed by tubercle bacilli in the sputum. Lu- 
pus, glanders and leprosy, all very rare diseases, may simulate the 
local appearances of tuberculosis, but the history of these is usually 
conclusive. In exceptional anomalous cases the diagnosis must 
be held in abeyance almost indefinitely. Pulmonary disease may 
be so deep-seated, or limited, as to give no signs, and, moreover, 
infection may take place in the larynx and may remain localized in 
that organ for a considerable time. In very rare cases of chronic 
laryngitis hypertrophy of the mucous membrane is so extreme 
as to resemble a tuberculous infiltration, but such a condition usually 
occurs in those whose occupation and habits account for the extra- 
ordinary thickening. The Roentgen ray bids fair to give positive 
testimony long before subjective pulmonary signs appear, and 
finally the ophthalmic and cutaneous tuberculin tests will help to 
remove doubt. 

In the laryngeal mirror the characteristic appearances of a tuber- 
culous larynx are the semi-solid, edematous infiltrations or the 
" worm-eaten" ulceration involving the epiglottis, the arytenoids, or 
the aryepiglottic folds. Usually the lesions are symmetrical or bilat- 
eral. The ulcer of tuberculosis is covered with pale granulations, 
its floor is not deeply excavated, and its edges are irregular and nib- 
bled, owing to the confluence of small marginal ulcerations and 
breaking down of minute tuberculous foci. There is seldom an 



344 DISEASES OF THE NOSE, THROAT AND EAR. 

areola as in cancer and syphilis; on the contrary, the surrounding 
parts are pale. 

The prognosis in tuberculous laryngitis is admittedly bad, but by 
no means hopeless. Life may be threatened by suffocation, by inani- 
tion, or death may occur from hemorrhage, yet the laryngeal lesion 
itself is seldom fatal except as it may interfere with the patient's 
nutrition through inability to swallow. Serious hemorrhage, 
unless of pulmonary origin, in laryngeal tuberculosis is extremely 
rare, and sudden stenosis from edema or swelling equally so. 

Treatment. — The fact must be recognized that in most cases the 
laryngeal lesion is simply one phenomenon in a constitutional disease. 
We are called upon to treat, however, not only the general condition 
but certain local lesions which interfere with the patient's comfort 
and tend to shorten his life. A prominent subjective symptom is the 
persistent cough. The neurotic element is, in some cases, very 
marked and is overcome in a measure by the use of sedatives, 
such as the bromide of potassium or sodium given in full doses, 
or small doses frequently repeated. It is important to protect 
the patient from irritating atmospheres as far as possible, to keep 
him in a uniform temperature, and to insist upon rest of the larynx 
and, when dysphagia is present, to provide nutriment easily swal- 
loAved and highly concentrated. It is found that large mouthfuls 
of food or drink are swallowed with less discomfort than small 
quantities. When odynphagia is very marked what is known as 
Wolfenden's method of feeding is resorted to with success. The 
patient is directed to lie prone upon the face with his head over the 
end of a lounge and is given nourishment in fluid form through a 
tube. Some patients who can swalloAv absolutely nothing without 
pain in the ordinary position are able to do so with ease when in this 
attitude. Hovell recommends a simple and but little known method 
of relieving pain in swallowing by means of firm pressure with the 
hands of one standing behind the patient. The pressure should be 
applied parallel with the posterior border of the ramus of the lower 
jaw, the fingers being directed upward, and gives greater relief 
the more firmly it is exerted. 

There is difference of opinion about the effect of altitude in 
laryngeal tuberculosis. It is very certain that some patients do well, 
while others do not thrive, at high altitudes. As a rule, if heart 
complications or weakness exist, and in acute tuberculosis, it is 



TUBERCULOSIS OF THE LARYNX. 345 

best to keep the patient near the sea level. It has been observed that 
tuberculous cases giving a history of long-standing antecedent catarrh 
which has advanced to atrophy do badly at high altitudes. 

The usual general medication of supportive character is to be 
adopted. Cod-liver oil, hypophosphites alone or combined with oil, 
and in some cases the glycerophosphates of lime or soda are useful. 
Shurly warmly advocates iodine internally. He claims the best 
results when it is combined with some proteid, and is accustomed 
to give it in bouillon or milk. Arsenic, creosote, guaiacol and many 
other drugs are employed with possible benefit. Tuberculin except 
as a diagnostic test, has been generally abandoned doubtless in 
consequence of its improper use. Its revival in much reduced 
doses is now being urged. It is impossible in a limited space to 
review all the internal remedies recommended at various times, 
and were all to be enumerated we should still be forced to the 
conclusion that at present a cure for tuberculosis does not exist. 
Our chief reliance in restricting and suppressing the disease must 
be upon a more faithful observance of hygienic laws in general and 
more stringent precautions as to those already infected. 

Fatty foods if assimilated seem to be of service. An excellent and 
somewhat palatable preparation of "mixed fats" (Russell emulsion) 
is generally well borne. Careful nutrition is important. Tubercu- 
lous patients should be encouraged to eat rather more than they seem 
to desire. The appetite may be stimulated with bitter tonics or alco- 
hol in moderation and well diluted. The present tendency is 
to discountenance the use of alcohol in any form, the position 
being taken by many that it actually favors the development of 
tuberculosis. Yet at least in the later stages the comfort it gives 
should not be denied. A life in the open air and sunshine should be 
urged. Avoidance of bodily fatigue and mental worry must be en- 
sured as far as possible. 

The local treatment of tuberculous laryngitis is in some degree 
encouraging. Soothing inhalations, such as compound tincture 
of benzoin, oil of pine, eucalyptus and menthol are indicated. They 
reduce hyperemia and irritation; and they correct a tendency to 
the formation of viscid secretions in the cavity of the larynx, the 
expulsion of which is accomplished with difficulty. Continuous 
local medication by means of persistent use of a perforated zinc 
inhaler charged with equal parts of creasote, alcohol and chloroform 



346 DISEASES OF THE NOSE, THROAT AND EAR. 

is strongly urged by Beverley Robinson. The most gratifying 
results are found in connection with the use of menthol. Whatever 
view may be held in regard to its antiseptic properties there is no 
question that it reduces congestion of the mucosa and renders the 
secretions more fluid and less tenacious. It may be applied directly 
to the diseased surface drop by drop with a laryngeal syringe in 
15 to 20 per cent, solution. At first it is quite pungent and even 
painful without cocaine, but in a few moments a cool soothing sensa- 
tion supervenes which is rather agreeable to most people. Menthol 
is soluble in olive oil or fluid albolene and is used in the larynx 
either hot or at ordinary temperature, whichever seems more grate- 
ful to the patient. Weak solutions used in a nebulizer at short 
intervals keep up a continuous effect and give as good results as 
those of greater strength. 

The use of iodoform, either by insufflation or in ethereal solution, 
or in oily emulsion has been much in vogue and still is highly 
recommended. It is more or less valuable in the ulcerative stage 
combined with morphine and an astringent, as follows: morphine, 
10 gr., tannic acid, 2 dr., iodoform. 6 dr. (Bosworth). This may 
be insufflated daily, care being taken not to use an excessive amount 
of the powder. One of the most promising substitutes for iodoform 
is formidine (methylen disalicylic acid iodide). It occurs as an 
impalpable, odorless powder, without staining qualities and possess- 
ing marked adhesive power of special value in the larynx. At times 
it causes some degree of pain owing to its liberation of formic alde- 
hyde. Formalin as a pigment in 1 to 10 per cent, solution is highly 
recommended by Lake, either alone, or preferably combined with 
lactic acid according to the following formula. Formalin, 7 per 
cent.; lactic acid, 50 per cent.; glycerine, 20 per cent.; and water to 
100 per cent. It is important to use a fresh preparation as the solu- 
tion loses its strength in a week or two. Formalin is also used in 
powder as presented under the name paraform. In efficient strength 
the applications are quite painful although the pain is not very lasting. 
Better results, as regards relief from pain and coughing, follow the 
use of orthoform, mixed with an equal quantity of powdered gum 
acacia or subnitrate of bismuth. It acts only on an ulcerated or 
abraded surface. The parts having been gently cleansed with a 
detergent are sprayed with a 2 per cent, solution of cocaine, eucaine, 
or alypin. Thus the surfaces are benumbed and the powder is 



TUBERCULOSIS OF THE LARYNX. 347 

not rejected by the act of coughing. The remarkable effects of 
insufflations of resorcin in promoting the repair of ulceration have 
been affirmed by McCall and others. It is best applied every other 
day mixed with orthoform in the proportion of one or two parts in 
three. These measures are almost certain to allay pain, and if 
resorted to shortly before food is to be given the nutrition of the 
patient may be sustained much more effectively than would other- 
wise be practicable. If they fail to arrest the cough we shall be 
compelled to have recourse to opium or one of its alkaloids, heroin, 
codein, or morphine. In irritable pharynges and especially in the 
hyperemic form of tuberculosis excellent results have been observed 
from spraying the larynx with a suprarenal extract solution contain- 
ing 1 grain of phenic acid to each drachm. In these cases it is 
important to use only a straight spray, the patient being taught to 
inhale at the moment. With a down spray there is danger of 
provoking spasm of the larynx and a violent paroxysm of coughing. 
Long curved tubes intended for insertion into the cavity of the larynx 
itself are quite unnecessary. 

The modern method of treating tuberculous laryngitis, by no 
means universally accepted, is based upon surgical principles as 
applied to deposits in other regions. An attempt is made to remove 
the diseased tissues by curetting, or excision, and to convert the tuber- 
culous lesion into a healthy granulaing ulcer by destruction of the 
morbid structures with a corrosive acid, preferably lactic acid. 
Many years ago the practice of puncturing the edematous and 
infiltrated tissues was proposed by Marcet. The painful tension 
often present in these tumefactions is thus relieved. According to 
Moritz Schmidt the swelling subsides and in addition beginning 
ulcerations heal. The fear once entertained of infection and 
ulceration of the wounds thus made is not supported by clinical 
experience. On the contrary repair takes place and relief of 
odynphagia is often complete. In this connection it should be 
noticed that spontaneous repair of tuberculous ulcers in the larynx 
has several times been observed. Tuberculous subjects, moreover, 
almost invariably improve temporarily under any new system of 
treatment and it is difficult at first to determine how much potency 
should be ascribed to a new drug or application. Much-vaunted 
specifics prove after extended trial to be inert. One after another 
they have to be abandoned and the search for an antidote must be 



348 



DISEASES OF THE NOSE, THROAT AND EAR. 



renewed. Hence we turn with hope to surgery, believing that 
although the disease itself may not be cured, prolonged suffering 
and a distressing death from ulcerative tuberculous laryngitis may 
be thereby averted. 

The details of treatment of a tuberculous larynx by curretting are 
described as follows. In the first place the patient may have to be 
put through a course of training in order to overcome the intolerance 
of the passages. It is impossible to perform any manipulations in 
the larynx satisfactorily unless the parts are under control. Usually, 




B D E P G HI J 

Fig. 135. — Heryng's Laryngeal Curettes and Scarifiers. 



even if they are very irritable, sufficient tolerance is established 
by a preliminary spraying of the larynx and fauces with a 10 per 
cent, solution of cocaine. In curetting the larynx the field of opera- 
tion is often obscured by the effusion of blood. This source of 
difficulty is in a measure obviated by the use of suprarenal extract 
in combination with cocaine. The ideal case for surgical treatment 
is one in which the tuberculous infiltration is situated at the posterior 
wall of the larynx, either in the region of the arytenoids or at 
the posterior commissure. Deposits in other situations are less 
accessible, but still if not too extensive they may be amenable 
to this mode of treatment. The parts having been prepared a 
laryngeal curette, of the model of Krause or Heryng (Fig. 135), 
is passed into the larynx under the guidance of the mirror and the 
affected surfaces are thoroughly and boldly scraped until we are 
reasonably sure that the tuberculous deposit has been completely re- 
moved, or has been sufficiently exposed. And here is the main diffi- 
culty. It is impossible to tell positively when the limits of the dis- 



TUBERCULOSIS OF THE LARYNX. 349 

ease have been reached. We are compelled to rely upon a judg- 
ment authorized by careful study of the parts beforehand. 

After bleeding has subsided we are ready for the application of the 
acid. The laryngeal applicator, wound at the end firmly with a 
small pledget of cotton and moistened with a solution of the acid, is 
passed into the larynx, the mirror showing the way as with the 
curette. It is not enough simply to touch the abraded surface; the 
acid must be thoroughly rubbed in. The help of the patient is 
needed, and he should be taught to hold the tongue firmly between 
the folds of a napkin with the thumb and forefinger of the right 
hand. Lactic acid is said to have an affinity for morbid tissue 
and does not act upon healthy mucous membrane. While this 
statement may be true we should never begin treatment with the full 
strength of the acid, and care should be taken to avoid using an 
excessive quantity. It is best at first to use not stronger than a 
20 per cent, solution, until we know what degree of reaction may 
be excited and how well the pain of the application may be endured, 
gradually increasing to full strength, if the patient is courageous and 
the parts not too sensitive. 

When the effect of the cocaine has worn off there is always more or 
less discomfort, and usually actual pain, which may last several hours. 
After the lapse of a week the process of rubbing in the acid is 
repeated with increased strength. The number of applications 
depends upon the situation and extent of the lesion and upon the 
effects. Usually we see, after the second or third application, an 
effort at repair of the ulcerated surface. It is well to suspend inter- 
ference for a week or two, or until signs of arrest of the reparative 
process, or of the development of new foci are evident. Cica- 
trization goes on with more or less rapidity until, in the course of 
two or three months, complete repair is attained. Unfortunately, 
however, the cicatrices show a tendency to break down, either 
because of the failure of complete extirpation of the disease, or of 
inherent weakness in the tissues. 

The use of lactic acid following curettage has many opponents, 
both because of the excessive pain incident to the treatment and for 
the more important reason that results are not uniformly satisfactory. 
Better results with practically no discomfort to the patient are claimed 
by Freudenthal for an elaboration of the menthol treatment proposed 
years ago by Rosenberg. The details arc as follows. The larynx 



350 DISEASES OF THE NOSE, THROAT AND EAR. 

is first thoroughly cleansed with some detergent solution, after 
which the parts are insufflated with three to six grains of powdered 
saccharated suprarenal gland. Cocaine has been discarded because 
of the paresthesia it causes in many patients, for the reason that it 
often affects the heart unfavorably, and finally on account of the 
fact that its solution is prone to decompose. These objections do 
not apply to powdered adrenal. After a few minutes an emulsion 
of menthol-orthoform made by the following formula is slowly 
instilled with a laryngeal syringe. 



S. 



Menthol 1-15 



Ol. amygdal. dulc 30 

Vitelli ovorum 25 

Orthoformi 12.5 

Aquae destell. q. s. ad 100 

Ft. emulsio. 

The relief from pain lasts seyeral hours or eyen days, so that a 
patient is able to take nourishment with ease. Under this method 
it is claimed that infiltrations disappear and ulcerations heal, and it 
apparently has no objectionable features. 

In the absence of ulceration excision of tuberculous masses may be 
effected with a double curette or punch forceps. Applications or 
injections of cocaine permit this to be done without extreme pain. 
It is only suited to cases of yery circumscribed disease. Indeed 
radical interference of any kind should be reseryed for limited 
ulcerations and infiltrations within easy reach, for primary laryngeal 
disease and for cases in which pulmonary disease is circumscribed, 
incipient, and quiescent. The principles goyerning the question as 
laid down by Heryng are belieyed to be logical. In brief he regards 
cases of adyanced pulmonary disease attended by hectic and emacia- 
tion, diffuse miliary tuberculosis and extreme inflammatory stenosis 
of the larynx as decidedly inappropriate for operation. In addition 
it is contraindicated in neurotic and timorous patients in bad general 
condition. When the epiglottis alone is inyolyed remoyal of this 
appendage through the mouth is feasible and entails no special incon- 
yenience. Such cases haye been reported by Solis-Cohen and Hajek, 
and R. Lake mentions haying three times remoyed the larger part 
of the epiglottis with the galyanocautery snare without pain and 
with good effect. Ulceration in this situation is often yery distress- 



TUBERCULOSIS OF THE LARYNX. 35 1 

ing, yet a patient under my observation has lost nearly one-third 
of his epiglottis and has never had a particle of pain. Attention 
has been called by Lake to the occurrence of postoperative pyrexia 
as a positive indication for discontinuing operative interference. 

In line with this mode of attacking tuberculosis of the larynx it 
may be mentioned that thyrotomy has several times been resorted to 
and that laryngectomy has been done fifteen times for actual or sup- 
posed tuberculosis, eight total and seven partial operations (Gleits- 
mann). It is hard to conceive that any circumstances would justify 
these procedures. On the theory that rest of the larynx is essential 
to secure repair of laryngeal ulcerations tracheotomy was practised 
for several years. My experience with it leads me to believe that it 
merely adds one more source of discomfort without commensurate 
advantage. When the condition has become so serious that feeding 
by enemata or with an esophageal tube must be considered the time 
for active treatment of any kind is past and palliation is our last 
resource. 

The influence of the chemical rays of light upon morbid processes 
has long been appreciated, and the subject has been recently taken up 
with renewed interest. In ancient times sun and air were considered 
essentials to health and life, and all the customs of the people were 
based on this idea. Electric light produces effects upon the system 
similar to those of sunlight, and modern phototherapy is the direct 
outcome of the old theory of light as a therapeutic agent. The 
conclusions reached by Sorgo and Kunwald are decidedly favorable. 
The former uses a rather elaborate system of mirrors, the latter the 
ordinary laryngoscope for reflecting the sunlight. Jessen, whose 
experiments have been made at a high altitude (Davos) is somewhat 
less enthusiastic and makes the pertinent suggestion that the good 
results are in part due to abstention from harsh and irritating 
measures while the solar treatment is being conducted. The power 
of sunlight at least to retard the growth of tubercle bacilli in culture 
tubes seems to have been demonstrated. The stimulus of light to 
the function of ciliated epithelium expedites chemical changes, or in 
other words oxidation, which result in activity. Thus the rays oi 
light do double duty in destroying germs and in exciting movements 
of cilia which serve to clear out secretions and irritating particles 
from the upper air-track. Especial attention has been given to this 
matter by Freudenthal, who has experimented with the arc light and 



352 DISEASES OF THE NOSE, THROAT AND EAR. 

the incandescent light in tuberculosis of the lungs as well as of the 
larynx. In cases of tuberculous ulceration and infiltration of the 
larynx the subjective symptoms were relieved and a definite cure of 
the laryngeal lesion was observed. This method, which is certainly 
free from disagreeable features, is deserving of further trial. In this 
connection the observations of Wolfenden and Ross as to the thera- 
peutic effect of the X-rays are of interest, their conclusion being that 
the rays stimulate rather than check the growth of bacilli. 

Submucous and intratracheal injections of various substances, as 
advocated by Watson Williams, Chappell, Donellan and others, 
have not been widely adopted. Creosote, guaiacol, 20 per cent., 
lactic acid, and biniodide of mercury, 1 to 1,000, seem to be effica- 
cious in some cases. The galvanocautery is used by a limited 
number, but is generally regarded as more or less dangerous. 
Williams in particular advises the galvanocautery point in the sub- 
glottic region for flat diffuse infiltrations which cannot be easily 
reached with forceps. In the experience of some it has never caused 
an acute edema of the glottis or violent reaction of any kind, and it 
is especially recommended by Gouguenheim and Tissier for fungous 
vegetations, or " pseudo-polypoid" formations. 

Electric cataphoresis, whereby the tissues are saturated with a 
medicament antagonistic to the morbific germ and stimulant to 
healthy repair, deserves more attention than it appears to have re- 
ceived. Guaiacol and oxychloride of copper have given the most 
satisfaction. Spherical electrodes of pure copper are preferred to 
needles for use in the larynx, since the former make no lesion of the 
mucous membrane. A weak galvanic current with the positive pole 
connected with the laryngeal electrode and the negative applied to 
the nape of the neck, is used every other day, the interval and 
the duration of the sittings being regulated by the strength of the 
patient and the results. Some throats are so irritable that this 
method is not feasible even with cocaine anesthesia. The following 
advantages are claimed for cupric electrolysis (Scheppegrell). (1) 
There is no destruction of tissue, or lesion of the surface through 
which pathogenic germs may reinfect the system. (2) There is no 
reaction nor hemorrhage. (3) It requires no extraordinary skill, 
and is especially easy when direct laryngoscopy (Kirstein) can be 
used. (4) It is applicable to all cases of laryngeal tuberculosis. 

Percutaneous galvanism and faradization have been used in tuber- 



TUBERCULOSIS OF THE LARYNX. 353 

culosis of the larynx to a limited extent with apparently definite and 
favorable results, but no final conclusion regarding them has been 
reached. 

It is somewhat the custom to pronounce the doom of an individual 
discovered to have tuberculosis and to content ourselves with efforts 
to ease his steps to the grave. Experience teaches that this desperate 
view should not be entertained. Although a large proportion of 
cases are inevitably fatal, yet we should not sit inactive and permit 
the ravages of the disease to go on unresisted. It is rather our duty, 
without relaxing the search for a remedial agent, to teach that hy- 
gienic living, pure air, and good food furnish the most effective 
weapons against the approach of the subtle enemy. As indispensable 
adjuvants we should insist upon voice rest, the avoidance of local 
irritants of every kind, the adoption of a diverting occupation, and 
abstention from overexertion and physical fatigue. All of these 
conditions, which render home treatment possible and most desirable, 
are at the command of only the well-to-do. Segregation of those 
less fortunate in hospitals and sanatoria should be under the strictest 
surveillance. Although tuberculous subjects are as a rule sanguine 
and cheerful, yet upon certain temperaments the depressing effect 
of intimate association with other invalids is quite detrimental. 

Suitable cases for surgical treatment are few; cures in the proper 
sense of the word are fewer still; but even from the most conservative 
standpoint, except in extreme cases, we have within reach the 
means which enable us to assure amelioration of symptoms' and 
prolongation of life. Obviously when called upon to treat a case Of 
laryngeal tuberculosis we are brought face to face with a complex 
problem to be viewed from many sides. We may at least refrain 
from inflicting additional torture upon the sufferer by useless and 
possibly harmful local meddling. 



23 



CHAPTER XXII. 

SYPHILIS OF THE LARYNX. 

The lesions of hereditary syphilis in the larynx are somewhat rare. 
It is admitted that a syphilitic dyscrasia is responsible for many 
derangements of the air-tract in the new-born, but that pathological 
phenomena characteristic of syphilis are as frequent in hereditary as 
in the acquired disease is by no means established. On the other 
hand J. N. Mackenzie believes that laryngeal lesions in congenital 
syphilis are not infrequent, and are simply not found because not 
sought. Two cases have been reported by Monti of syphilitic devel- 
opment in the larynx in intra-uterine life. A division into secondary 
and tertiary is not practicable, the first manifestations of hereditary 
syphilis often being deep destructive ulcerations. Usually the 
laryngeal lesions are associated with or follow characteristic affections 
of the eye, malformations of the teeth, or other phenomena distinc- 
tive of syphilis. Two-thirds of the cases occur in the first year 
of life. Alteration of the voice and of the cry of the child, the occur- 
rence of cough, dyspnea and attacks of laryngismus are commonly 
observed. Laryngoscopy is difficult but by no means impossible in 
the early years of life. Kirstein's mode of examining the larynx 
is feasible when the ordinary methods fail. 

The best treatment of hereditary syphilis of the larynx consists of 
inunctions with mercurial ointment or the internal administration of 
gray powder. Some cases do better when mercury is combined with 
the iodides or hydriodic acid, or with general tonics. 

Locally, mentholized or borated albolene in vapor or spray has a 
beneficial effect. The question often arises whether in the presence 
of active hereditary disease, enlarged tonsils and adenoids should 
be removed. The coexistence of a syphilitic taint should certainly 
not be regarded as a contraindication, if it is evident that these 
hypertrophies are making an impression upon the general health. 
Intralaryngeal infiltration or distortion from cicatricial contraction 
may so impair the lumen of the child's larynx as to suggest the 
necessity of tracheotomy or intubation. The latter mode of re- 

354 



SYPHILIS OF THE LARYNX. 355 

lieving the stenosis is preferable unless an excessive amount of 
cicatricial tissue be present. If the obstruction of the larynx 
has come on rather gradually it is probably due to cicatrices and, 
whether in children or adults, we are confronted by a most serious 
complication which is capable of relief only after a very tedious and 
rather unsatisfactory course of treatment. Internal medication can- 
not be expected to make any impression on adventitious bands of 
scar tissue, and we are forced to choose between the introduction of a 
trachea tube, an intubation, and division with dilatation of the stric- 
ture. A tracheotomy may be required as a preliminary to attempts 
to overcome the stenosis by the use of bougies. Months and even 
years may be spent in the process of stretching a syphilitic stricture 
of the larynx and after all the result may not be permanent. In any 
case the phonatory function of the larynx will have been impaired or 
lost. Experience with the O'Dwyer tube of vulcanite or metal is 
quite encouraging. The metal tube has a proportionately larger 
lumen and its weight tends to keep it in place. In one of O'Dwyer's 
cases the tube was worn upward of a year. In exhaustive reports 
on this subject by Lefferts and by W. K. Simpson abundant evi- 
dence appears of the value of intubation in these cases and of the 
ease with which the tube is tolerated for a very long period. In 
view of the tardy and often disappointing results from this method 
partial resection of the larynx has been advocated by certain authori- 
ties. Schroetter, a most enthusiastic partisan of systematic dilata- 
tion after tracheotomy, has had several successful cases with the use of 
tubes of gradually increasing diameter, and similar success has been 
achieved by others (Fig. 136). Dilatation from below through a 
trachea tube has been recommended by Stoerk and is preferable 
in some cases. Rapid stretching of a syphilitic stricture is almost 
invariably followed by excessive inflammatory reaction and should 
never be employed. The "dilating laryngotome" of Whistler, an 
almond-shaped dilator in which is concealed a knife blade to be pro- 
truded by a lever in the handle of the instrument, seems to have given 
excellent satisfaction in many cases. It has been modified by 
Lennox Browne by making the shaft of the instrument hollow and 
thus the operator is enabled to make the incisions with more delibera- 
tion and certainty without fear of completely obstructing the air- 
tract. The results of treatment are much more gratifying and per- 
manent in the larynx, as elsewhere, provided the bands of scar tissue 



35& DISEASES OF THE NOSE, THROAT AND EAR. 

are thin and not very numerous. In many cases, especially if the 
stenosis involves the trachea as well as the larynx, the only resource 
is a trachea tube to be inserted as low as possible and permanently 
retained. Stenosis of the larynx developing somewhat rapidly is 
generally caused by edema or by gummatous infiltration. The mar- 
vellous and prompt relief given in these cases by internal medication, 
even when a tracheotomy seems unavoidable, has been insisted upon 
by Krishaber and others. A boy, ten years of age, was once brought 
into my clinic cyanotic and gasping for breath. There was no 




Fig. 136. — Schroetter's -Laryngeal Dilator. 

The metal plug is attached to the introducer by a twine which is drawn through 
the hollow handle by means of the slender flexible hook. The plug fits into the fenestra 
of the trachea tube and is held in place by the inner tube the upper part of which is 
prolonged as a solid rod. 



time to ask questions, so I at once opened the trachea. The his- 
tory of the case afterward obtained proved clearly that the boy was 
a victim of hereditary syphilis. The usual treatment was followed 
in a few days by subsidence of the laryngeal stenosis so that it was 
possible to remove the trachea tube. The laryngoscope showed ex- 
treme deformity of the larynx from old ulceration and cicatricial 
bands, but the breathing space was ample and very likely might have 
been rendered so by internal medication alone without the aid of a 
tracheotomy. 

The lesions of acquired syphilis of the larynx are limited to those 
of the so-called secondary and tertiary periods. Wide discrepancies 



SYPHILIS OF THE LARYNX. 



357 



exist among authorities as to the frequency of its occurrence, one 
observer having met with it in only 2.9 per cent. (Lewin) of all 
laryngeal cases observed; another found it in 34 per cent. (Som- 
merbrodt) . 

Predisposing causes of syphilis of the larynx in the acquired dis- 
ease are catarrhal conditions, neglect of treatment in the early 
stages, and bad hygiene such as often prevails among the poorer 
classes. Primary syphilis has not been met with in the laryngeal 
cavity. A case of chancre of the epiglottis reported by Moure is 
unique. 




Fig. 137. — Early Secondary Lesions of Vocal Bands. (Schnitzler.) 



Secondary lesions generally coexist with a cutaneous eruption, or 
closely follow it. An erythema of the larynx is very apt to accom- 
pany a similar condition in the fauces, and differs but little from a 
simple erythema except that the redness of the former is less intense 
and less diffuse, the membrane having a mottled appearance. It 
causes no symptoms of importance except more or less hoarseness, 
and requires no very energetic local treatment (Fig. 13 7V 

The occurrence of mucous patches in the larynx has been denied 
by many excellent observers, but numerous authentic cases are 
now on record. When present on the epiglottis they often appear 
as condylomata or warty excrescences. These lesions are seldom 
symmetrical. They disappear under treatment or spontaneously 
but are prone to recur. They are often found associated with gen- 



358 DISEASES OF THE NOSE, THROAT AND EAR. 

eral erythema which involves the pharynx as well. They may be 
single or multiple and in the mirror present the appearances charac- 
teristic of mucous patches in other regions, namely, elevated erosions 
with a surface of a peculiar grayish hue and surrounded by a more 
or less pronounced areola of redness. It is quite probable that 
mucous patches in the larynx often fail to attract attention on 
account of the slight functional disturbance they excite, and of the 
greater importance of coincident symptoms. 

The form of superficial ulceration named by Whistler "relapsing 
ulcerative laryngitis" possibly begins as a mucous patch. The voice 
is generally husky and raucous. The singing voice is absolutely 
abolished and the probability of its recovery is very doubtful. 
Respiration is wheezy. There is more or less irritating cough 
without an excessive amount of expectoration. There is seldom 
any pain. In examining the larynx with a mirror we find instead 
of a uniform redness of the mucosa a mottled hyperemia, and 
erosive patches are seen on the ventricular bands, upon the free 
edge of the epiglottis, on the arytenoids, or at the posterior commis- 
sure. Gottstein describes them as " round or elongated grayish- 
white spots of thickened epithelium, slightly raised above the con- 
gested tissue which surrounds them, and either sharply circumscribed 
or shading off into the congested mucous membrane." Ordinarily, 
there is no very obvious change in the texture and conformation of 
the mucous lining of the larynx except in the existence of diffuse 
condylomata. Occasionally the edges of the vocal bands are 
eroded or notched and adhering to them are seen masses of viscid 
secretion. Usually confirmatory symptoms elsewhere in the body 
are present. A cutaneous eruption, posterior cervical or epi- 
trochlear lymphadenitis, or some of the other well-known symptoms 
of secondary syphilis, establish the diagnosis. The impairment of 
general health is no more than might be reasonably expected 
from the systemic disturbance unless the laryngeal lesions are so 
aggravated as to interfere with rest at night, or with comfort by 
day (Fig. 138). 

The so-called tertiary lesions of acquired syphilis are of much more 
serious importance. They begin in the deeper tissues or reach 
them by extension from the surface of the mucous membrane. 
They occur as gummatous tumors or infiltration and as ulcerations 
superficial or deep, resulting from disintegration of gummatous infil- 



SYPHILIS OF THE LARYNX. 359 

tration. The latter present the form of circular or crescentic ulcers, 
with sharp elevated edges, sometimes undermined, surrounded by an 
inflamed areola. The color of the mucous membrane is somewhat 
less red than in simple inflammations. The resultant deformity 
varies with the degree of infiltration, the loss of tissue, or the disposi- 
tion and extent of cicatricial formations. The effect upon the voice 
depends entirely upon the site of the lesion, whether upon the vocal 
bands themselves or at some point where the action of the intrinsic 
muscles of the larynx is only slightly interfered with. Dyspnea may 




Fig. 138. — Superficial Lesions of Vocal Bands in Early Syphilis 
(Schnitzler.) 



be due to infiltration, cicatricial contraction, edema, or anchylosis of 
the cricoarytenoid joint. More or less cough is usually present, and 
the expectoration is sometimes streaked with blood when an active 
ulcerative process is present. Deglutition may be impaired and pain- 
ful if an ulcer involves the margin of the glottis. There may be no 
cachexia or impression upon the general health unless swallowing is 
interfered with (Fig. 139). 

In all therapeutics there is no more satisfactory and definite result 
of treatment than in the disappearance of a gummy tumor under the 
influence of iodide of potash, provided the stage of softening has not 
been reached. It is a remarkable fact that one of these tumors may 
remain quiescent for months or even years and then from some 
inexplicable cause begin to break down and ulcerate. A gummat- 
ous infiltration may be diffuse or in the form of circumscribed tumor. 
single of multiple. Dyspnea is proportionate to the degree oi en- 



360 DISEASES OF THE NOSE, THROAT AND EAR. 

croachment on the respiratory track and interference with phonation 
varies with the relation of the lesion to the vocal bands. There is 
always danger of an access of inflammation or edema which may 
cause a dangerous stenosis. There is seldom much pain unless the 
rim of the glottis is involved in ulceration, or the perichondrium and 
the cartilages become affected. Necrosis or caries of the cartilage 
may take place. A fragment of dead cartilage may be extruded in 
the act of coughing, or may become embedded in a dense mass of 
cicatricial tissue. , Usually a gummy tumor develops rather rapidly 
and presents as a symmetrical painless tumefaction covered by nor- 
mal mucous membrane. It is impossible in the absence of a positive 





Fig. 130. — Destruction of Vocal Bands by Late Syphilitic Ulceration. 
(Schnitzler.) 



specific history, to differentiate the condition from a malignant 
neoplasm without resort to a test with antisyphilitic treatment. 
The importance of recognizing a gummy tumor before the process 
of disintegration has begun must be obvious. When ulceration 
is established we have to look forward to the deformity from 
distorting scars which always follows repair of a syphilitic ulcer. 

The prognosis in tertiary syphilis should be guarded. The patient 
is in danger from edema implanted upon a more or less extensive 
infiltration, or from hemorrhage due to invasion of a blood-vessel 
by an ulcerative process. 

The treatment should be active and in accordance with the method 
of treating syphilis in general. In secondary laryngeal lesions mer- 
curials are indicated and, locally, the condition should be handled by 
soothing or stimulating inhalations as in simple chronic laryngitis. 
Nitrate of silver, unless ulcerations are present, is best avoided from 
its tendency to promote hyperplasia. In the deeper tertiary lesions 



SYPHILIS OF THE LARYNX. 36 1 

the iodides in rapidly increasing doses, combined with cod-liver oil 
and general tonics, and alternating with mercurial inunctions, or 
injections or used together with them, give the best results. In the 
tertiary ulcers, nitrate of silver in strong solutions, or fused on a probe, 
and even the galvanocautery, may be required to stimulate healthy 
reparative action. Stenosis due to infiltration usually yields to 
saturation of the system with iodides. The management of that 
resulting from cicatricial contraction has been described. 



CHAPTER XXIII. 

NEUROSES OF THE LARYNX. HYPERESTHESIA. ANESTHESIA. PARES- 
THESIA. NEURALGIA. HYSTERICAL APHONIA. LARYNGEAL 
VERTIGO. CHOREA. SPASM OF THE LARYNX. LARYN- 
GEAL STRIDOR AND WHISTLING. PARALYSIS OF 
THE LARYNX. 

SENSORY NEUROSES. HYPERESTHESIA OF THE 

LARYNX. 

Hyperesthesia, or excessive sensitiveness of the larynx, is usually 
symptomatic of some inflammatory condition, and is especially noted 
in phthisis and in carcinoma. The degree of normal sensitiveness 
differs greatly in different individuals and is apt to be more marked 
in those of nervous temperament. It is exaggerated in alcoholics, 
while, in syphilis, it is usually diminished. In conjunction with 
abnormal pallor of the mucous membrane it must be regarded as of 
rather serious import in relation to the probable development of 
tuberculosis. 

ANESTHESIA OF THE LARYNX. 

Anesthesia of the larynx may result from some lesion involving the 
trunk of the superior laryngeal nerve. It is frequently marked in 
central nervous troubles, in hysteria, and as a sequel of diphtheria. 
In some cases of chronic laryngitis there is diminution in the sensi- 
tiveness of the laryngeal mucosa. In anesthesia of central or bulbar 
origin nothing can be effected by treatment. In other cases the use 
of nerve tonics is indicated, and faradism is of service, the internal 
electrode being placed in the sinus pyriformis in order to bring it as 
near as possible to the superior laryngeal nerve (Ziemssen). If the 
lesion is bilateral there is danger from the entrance of food or foreign 
bodies into the air passages. 

362 



NEURALGIA OF THE LARYNX. 363 



PARESTHESIA OF THE LARYNX. 

Paresthesia, or perverted sensation, of the larynx, includes burn- 
ing, tickling, a sensation of a foreign body, a constant desire to swal- 
low, and a simple feeling of irritation. It may be associated with 
some organic structural lesion, or the consequence of lymphoid 
hypertrophy at the base of the tongue. It may occur as a reflex 
phenomenon from disease in some remote region, or it may be merely 
a symptom of neurasthenia or hysteria. The tickling sensation is 
very annoying, and occurring in the course of certain tuberculous 
lesions of the larynx and in neurotic subject, is provocative of dis- 
tressing cough. 



NEURALGIA OF THE LARYNX. 

Neuralgia of the larynx is said to occur in the course of rheuma- 
tism and gout and in malaria. Pain is a prominent symptom in can- 
cer and phthisis and in connection with some acute inflammatory 
troubles, but genuine functional neuralgia of the larynx is believed 
to be a rare occurrence. Associated with spontaneous pain there 
may be tenderness on pressure over the larynx externally, especially 
in the vicinity of the greater cornu of the hyoid. There is no abnor- 
mal appearance to be seen in the laryngeal mirror. Reported cases, 
like that of Schnitzler, in which the pain was so intense that the 
patient was on the verge of suicide, and which was cured by brushing 
the larynx with a solution of chloroform and morphine, and like 
that of Bosworth, in which tracheotomy was contemplated for the 
relief of a sense of suffocation and in which a cure was effected by 
aconitia pushed to its physiological effect, would suggest that the 
condition must be regarded as, in large part, hysterical. In all 
probability, any pronounced impression would have induced a cure. 
Such cases are amenable to hypnotic suggestion. Most of these 
sensory neuroses occur in neurotic subjects and in those in impaired 
general health. The indications then are clearly for the use of 
general tonics and good hygiene, combined with mental diversion. 
The galvanic current, the positive pole in the larynx, has been found 
beneficial. 



364 DISEASES OF THE NOSE, THROAT AND EAR. 

MOTOR NEUROSES. HYSTERICAL APHONIA. 

An interesting functional neurosis not infrequently met with in 
females, hysterical aphonia, is characterized by complete loss of voice 
without any gross lesion of the larynx. Phonatory movements of the 
larynx are symmetrical but incomplete; the cords fail to approximate 
in attempts at phonation, or at once retreat after momentary adduc- 
tion, and the patient merely succeeds in producing a whisper. The 
loss of voice is as complete as in inflammatory conditions, but 
while the laryngeal picture in the latter is abnormal, in hysterical 
aphonia there is no deviation from health. The ability to cough is 
retained, this condition thus differing from a genuine paralysis, and 
under general anesthesia phonatory power is restored. There 
is rarely any interference with breathing, a single case having been 




Fig. 140. — Hysterical Paralysis of Adductors. (Schnitzler.) 

reported by Meschede in which the affection simulated bilateral ab- 
ductor paralysis, and the necessity of opening the trachea was being 
considered, when the voice was suddenly recovered and the dyspnea 
ceased. The loss of voice and its recovery are generally equally 
abrupt. The occurrence of sudden shock or extreme excitement 
acts as a stimulant to phonation or, if any doubt remains as to the 
character of the trouble, the administration of an anesthetic will clear 
it up. Not infrequently hysterical aphonia is of reflex character 
dependent upon uterine disease, or upon some lesion in the nasal 
chambers or the naso-pharynx (Fig. 140). 

LARYNGEAL VERTIGO. 

Laryngeal vert go, also called laryngeal apoplexy, laryngeal syn- 
cope and complete glottic spasm, is a rare condition usually preceded 
by a sensation of tickling or discomfort in the larynx and paroxysmal 



LARYNGEAL VERTIGO. 365 

cough. The patient grows dizzy, generally falls, becomes momen- 
tarily unconscious, and presently recovers without any subsequent ill 
effects. There are sometimes congestion of the face and slight 
convulsive movements which are not to be confounded with those 
of true epilepsy. The condition resembles the epileptiform seizures 
which occur in tabes. There is no laryngeal lesion discoverable. 
Charcot likens it to Meniere's disease and believes it is reflex in 
character. Nearly all the cases observed were in males past middle 
life. The attacks vary from a single one to as many as fifteen 
a day (Charcot). McBride believes they are due to forced expira- 
tory efforts against a partially closed glottis which causes congestion 
as in prolonged paroxysmal cough and whooping-cough. F. I. 
Knight, who has made a careful study of this subject, corroborates 
the views of McBride in large part, but notes the fact that the 
presence of spasm of the glottis in most cases has not been proved, 
and he surmises that even in its absence the head symptoms and 
loss of consciousness may be readily explained by the disturbance 
of the cerebral circulation consequent upon rapid respiration. 

The prognosis is good. There is seldom any serious complication 
and the correction of local disease or general disturbance is followed 
by disappearance of the laryngeal symptoms. In all cases careful 
examination should be made of the pharynx, base of the tongue 
and upper air-tract; not infrequently hyperemia or varix at the 
base of the tongue is discovered which is relieved by the use of 
the galvanocautery. Astringent applications to the pharynx and 
counter-irritation over the larynx have been recommended. 

In some cases the bromides or other nerve sedatives, iron, ergot 
and salines are beneficial and careful attention should be paid to 
the diet and the condition of the digestive tract. Stimulants should 
be avoided. 

CHOREA OF THE LARYNX. 

Chorea of the larynx usually occurs in connection with some other 
neurotic symptom or with general chorea. Almost invariably a local 
lesion like an elongated uvula, hypertrophy of the glands at the base 
of the tongue, or enlarged tonsils coexists as an exciting cause. 
The most conspicuous symptom is a dry explosive cough at short 
intervals through the day only. The voice is not affected, although 



366 DISEASES OF THE NOSE, THROAT AND EAR. 

phonation may be somewhat jerky. It is usually met with in girls 
approaching maturity, although one case has been observed at the 
age of forty-two (F. I. Knight) . Gottstein believes that many of these 
cases are examples of so-called "nervous cough" rather than a 
genuine chorea, but so many cases have been reported by such care- 
ful observers as Lefferts, Roe and others that there can be no doubt 
as to the occasional occurrence of true choreic spasm of the glottis. 
The best results in treatment have followed the adoption of good 
hygiene, the use of electricity, bromide of potassium internally, 
or Fowler's solution in physiological doses. In all cases nasal 
stenosis should be corrected, and the abnormalities above referred 
to must be removed. 

SPASTIC APHONIA. 

Spastic aphonia, or dysphonia, is the name given to a condition of 
adductor spasm occurring on attempts at phonation and ceasing 
when the effort to speak is discontinued. It has been observed 
only in adults and generally in females. It is apt to follow overuse 
of the voice and has been compared by Schnitzler to " writer's 
cramp." In some cases the cartilaginous portion of the glottis re- 
mains open, in others the adduction is so forcible that the vocal bands 
actually overlap and stenosis is complete. In some the spasmodic 
movements are irregular, or clonic, producing what has been called 
by James " stammering of the vocal cords." At times the at- 
tacks increase in frequency and severity and are finally excited 
by other causes than the attempt to speak. Distinct pain or a feel- 
ing of cramp in the region of the larynx is sometimes present. 

SPASM OF THE LARYNX IN CHILDREN. LARYNGIS- 
MUS STRIDULUS. 

Spasm of the larynx, or paroxysmal closure of the glottis, may be 
caused by some irritation of the recurrent laryngeal nerve, or of the 
trunk of the vagus, or may be of purely reflex origin, as from aden- 
oids, difficult dentition or intestinal parasites. In children it is most 
common in the first two years of life and may be produced by very 
slight causes. It is more frequent in male children and in the winter 
months. Ill-nourished rachitic children are especially prone to 



SPASM OF THE LARYNX. 367 

laryngismus. In these cases also glandular enlargements, particu- 
larly affections of the bronchial glands, and diseases of the nervous 
system, notably hydrocephalus, are named as etiological factors. In 
children of highly nervous temperament a catarrhal inflammation of 
the larynx, or of the air-tract generally, gastric or intestinal irritation, 
or any profound emotion may induce an attack. Usually there 
are no premonitory symptoms. The child goes to sleep at night in 
usual health, is suddenly wakened and after giving two or more 
short crowing inspirations ceases to breathe. After a few seconds 
and several long noisy inspirations normal respiration is resumed 
Such attacks are repeated at short intervals and interfere but little 
with health or comfort except at the time. In more severe cases the 
muscles of the extremities are involved and general tonic convulsions 
occur, with momentary loss of consciousness and irregular heart 
action. Attacks of this type are very terrifying as well as dangerous. 
In milder cases it is noticed that the paroxysms are more apt to 
come on at night and that the intervals between them are shorter. 

The prognosis is generally good, the liability disappearing with 
improvement in nutrition and decrease of nervous irritability. 
Death occasionally occurs in weak children from asphyxia or general 
convulsions. A fatal result may also follow from pressure due to 
effusion in the ventricles of the brain. When the attacks are severe 
and frequent so that the general health begins to suffer the outlook 
is less favorable. 

In the treatment of this condition it is important that attention be 
directed to the general health with a view of warding off the attacks. 
At the same time the paroxysm itself must be relieved if possible, 
although it is clear that many of the measures resorted to under these 
circumstances are utterly useless. Yet in the presence of relatives 
frantic with fear and of a child cyanotic and apparently dying from 
apnea we are obliged to do something. In severe cases swallowing 
is impossible and respiration is suspended so that we are debarred 
from the use of internal remedies and inhalations until the spasm 
subsides. Tight clothing should be loosened and a supply of fresh 
air furnished by opening the windows. Friction of the extremities 
and purgative enemata are indicated. Immersion in a hot bath with 
cold affusions to the head is useful. When the spasm does not 
yield catheterization of the larynx, intubation, or tracheotomy is 
called for. The first mentioned is recommended bv Gottstein. 



368 DISEASES OF THE NOSE, THROAT AND EAR. 

Artificial respiration and possibly stimulation of breathing by elec- 
tricity maybe of service. As a rule, the case terminates by relaxation 
of the spasm or asphyxia before these resources can be made 
available. In the intervals the diet must be carefully regulated as 
regards both quantity and quality of food. Gastrointestinal de- 
rangements must be corrected and excessive nervous irritability 
controlled by sedatives, especially bromide of potash. Antipyrine 
has been used successfully, and various antispasmodics are now and 
then resorted to. Rickets, struma, lymphadenitis, anemia and other 
constitutional disorders require appropriate treatment. The use of 
morphine would probably be considered inadvisable by most practi- 
tioners, yet Bosworth regards a sixteenth of a grain of morphine 
combined with one five-hundredth of atropine hypodermic ally 
as effective and quite safe in a child of eighteen months. Scarifica- 
tion of the gums should be done in impeded dentition, and feeding 
with a spoon instead of allowing the child to take the breast, when 
as occasionally happens the act of nursing seems to excite an attack, 
should be tried. In high-strung nervous children the avoidance of 
undue excitement is very important. 

SPASM OF THE LARYXX IX ADULTS. 

The occurrence of spasm of the larynx in adults is very rare. 
Among the most frequent causes may be mentioned hysteria and 
pressure upon the pneumogastric or inferior laryngeal nerve by a 
new growth or an aneurysmal tumor, the compression being suffi- 
cient merely to irritate the nerve trunk without completely impeding 
its function. In epilepsy, hydrophobia, tetanus, chorea and loco- 
motor ataxia spasm of the glottis is not uncommon. It frequently 
follows a local application to the larynx, especially if much force be 
used or the character of the application be irritating. Foreign bodies 
are very apt to provoke a spasm; neoplasms are less likely to do so 
because in their process of slow development the parts become accus- 
tomed to their presence. Bosworth refers to cases cured by correc- 
tion of a deviated septum, reduction of nasal hypertrophies and 
removal of nasal polypi, and mentions having seen "some very 
interesting cases of laryngeal spasm in the chronic pharyngitis of 
alcoholism." A unique and perhaps dubious case is that of Hack in 
which the spasm is supposed to have been induced by a hyperemic 



NEUROSES OF THE LARYNX. 369 

condition of the mucous membrane of the pyriform sinus in which 
situation the superior laryngeal nerve is quite superficial. Except 
when occurring as a phenomenon of locomotor ataxia the seizures are 
generally nocturnal. They are very transient and seldom involve 
any danger to life except in tabes, although Heryng reports several 
cases of reflex spasm from intranasal disease in which tracheotomy 
was required. The treatment of the case otherwise depends upon 
the cause. Local lesions of the upper air-tract must be corrected 
and so-called nerve tonics and sedatives are indicated. Nearly all 
patients of this class are below par in general health and in a state 
of nervous erethism which predisposes them to all sorts of functional 
disturbances. Any modification of regime or habits which may con- 
tribute to improvement in these particulars must be enforced. 

LARYNGEAL STRIDOR AND LARYNGEAL WHISTLING. 

Two curious conditions are met with in young patients which may 
be mistaken for more serious lesions. The first, aryngeal stridor, 
appears in infants at or soon after birth, and is rarely accompanied 
by cyanosis and dyspnea. There is no aphonia. A difference of 
opinion exists as to its cause. It resembles ordinary laryngismus 
stridulus and has been considered by some a reflex spasm due to 
adenoids. The theory that it is due to hypertrophy of the thymus 
gland is strenuously advocated by Hochsinger, who moreover finds 
a large proportion of cases exhibiting a condition of rickets often 
with coincident enlargement of the spleen. Others believe that it 
is caused by para ysis of the posterior crico-arytenoid muscle, or 
compression by bronchial glands. It seems probable, however, that 
it is due simply to unusual flaccidity of the laryngeal structures 
(Sutherland and Lack). The epiglottis folds on itself and the resil- 
ient walls of the larynx tend to collapse, thus impeding respiration. 
The condition is rarely dangerous and ordinarily requires no special 
treatment. Examination of the larynx is not easy and it might be 
difficult to differentiate this condition from that resulting from papil- 
lomatous growths or membranous obstruction. 

After a very thorough study of the subject, A. Logan Turner and 

John Thomson reach the following conclusions: that the stridor is 

due to disturbance of respiratory coordination probably resulting 

from faulty or retarded development of the conical center; that the 

24 



370 DISEASES OF THE NOSE, THROAT AND EAR. 

altered conformation of the larynx is not congenital but is merely an 
exaggeration of the infantile type resulting from the constant sucking 
in of the aperture of the soft larynx in the peculiar breathing; that the 
sound is not pharyngeal nor tracheal, but is made in the larynx; that 
this neurosis is not due to adenoids or other reflex irritation. They 
believe that enlargement of the thymus or lymphatic glands is not 
concerned, because these lesions were not found in several cases 
examined post mortem, and because in two cases of pressure from 
enlarged glands the stridor was chiefly expiratory, the larynx did not 
move up and down in respiration, and respiratory distress was much 
more marked than it commonly is in cases of intralaryngeal obstruc- 
tion. It is supposed that the stridor in the class of cases under dis- 
cussion is produced partly in the larynx and partly by abnormal 
approximation of the aryepiglottic folds. 

A very rare and curious phenomenon has been described under the 
name of "laryngeal whistling." A recent case was that of a boy of 
thirteen who produced a strange shrill whistle with the mouth wide 
open. It was possible to examine the boy with a mirror, but it was 
found in the production of the sound that the epiglottis was forcibly 
drawn downward so as to prevent a view of the interior of the 
larynx; hence, it was impossible to determine precisely the origin of 
the sound, whether produced in the chink formed by forcible retrac- 
tion of the epiglottis, or by the aryepiglottic folds, or by an extraor- 
dinary degree of tension of the cricothyroid muscles over which the 
patient may have had an unusual amount of control. It has 
been suggested also that this lad might have caused the sound with 
a membranous formation similar to the syrinx of birds. In a similar 
case reported several years ago by John O. Roe it was possible to 
study the parts during production of the sound, the patient being an 
adult and very manageable. This observer concludes that the 
whistle was produced by vibration of the vocal bands only in their 
middle third, the limitation of their action being assisted by contrac- 
tion and depression of the ventricular bands. In high tones the 
arytenoids were seen to be forcibly drawn up under the epiglottis. A 
similar mechanism was found in the case of a professional ventrilo- 
quist in producing the primary ventriloquial tones, although he could 
not make a laryngeal whistle. The explanation here offered was 
confirmed by Elsberg in two cases of his own, and several other 
examples of this curious phenomena are quoted. A different ex- 



PARALYSIS OF THE LARYNX. 37 1 

planation is given by G. Hudson Makuen, and it may be that the 
feat of laryngeal whistling is capable of performance in various 
ways. He had an excellent opportunity to study the condition in the 
case of a young man who could whistle a tune with his mouth open. 
He found and was able to demonstrate to others that the aryepi- 
glottic folds were pursed up precisely as the mouth is in whistling 
and that no other part of the larynx was used, the vocal bands 
having no more share in the laryngeal whistle than in the ordinary 
lip whistle. In still another case reported by C. E. Munger the 
ventricular bands seemed to be chiefly concerned, space for the air 
blast being left at the posterior fourth of the vocal bands which were 
elsewhere in firm contact. 

PARALYSIS OF THE LARYNX. 

Interference with the action of the laryngeal muscles may be of 
myopathic origin or referable to some lesion of the nervous system, 
either central or of one of the laryngeal nerves in continuity. A 
typical example of the former is seen in the aphonia occurring 
in tuberculous laryngitis, due, in part, to mechanical interference with 
muscular movements by infiltration at the posterior commissure, and, 
in part, to a general muscular atony. 

A very common form of myopathic paralysis occurs in the loss of 
power of the thyroarytenoid muscles resulting from overuse of the 
larynx when inflamed. Fatigue from muscular strain, whether 
in speaking or singing, often results in this condition. The thyro- 
arytenoid muscles are the most important and interesting of the in- 
trinsic muscles of the larynx as regards purity and sweetness of tone. 
Some of their fibers are distributed to the margin of the cord and 
are capable of limiting vibration to one portion of the vocal band. It 
is easy then to appreciate how inflammation of the bands may inter- 
fere with their delicate mechanism. Impairment of the action of 
these muscles produces very marked alteration in timbre and range 
of the voice, which is weakened or altogether lost. The larvn- 
goscopic picture is perfectly characteristic and unmistakable. 
Instead of a close approximation of the cords an elliptic opening 
from the vocal process to the anterior commissure remains on at- 
tempts at phonation. A similar picture is presented, only to a more 
marked degree, when the cricothyroid muscle is paralyzed ^Fig. 141). 



37 2 



DISEASES OF THE NOSE, THROAT AND EAR. 



The arytenoideus muscle is affected by lesions of the inferior 
as well as of the superior laryngeal nerve (Fig. 142). When 
the latter nerve is involved the cricothyroid muscle is paralyzed, 
an elliptic opening, as in thyroarytenoid paralysis, is seen and a 
triangular space exists at the posterior commissure, the vocal bands 
being in contact only at the vocal processes. This muscle may 
also suffer in connection with a chronic catarrhal laryngitis, in 





Fig. 141. — Bilateral Paralysis of 
Internal Thyroarytenoids. 



Fig. 142. — Paralysis of Arytenoideus. 



incipient tuberculosis, in diphtheria and in hysteria. The voice 
is hoarse, feeble, or entirely lost, attempts at phonation being very 
tiresome owing to waste of air in the expiratory blast (Fig. 143). 

Bilateral paralysis of the lateral cricoarytenoids is a very rare con- 
dition. The laryngeal image is almost identical with that of bilateral 
paralysis of the recurrent laryngeal nerve. It may result from lead- 
poisoning, diphtheria, or from one of the exanthemata. 




Fig. 143. — Paralysis of Internal Thyroarytenoids and of Arytenoideus. 



Unilateral paralysis is also very infrequent and is due to causes 
similar to those just mentioned. It is characterized by impaired 
rather than complete loss of voice, the unaffected cord attempting to 
compensate for the paralysis of the opposite cord by crossing the 
middle line, the arytenoid cartilage on the sound side passing in 
front of the opposite arytenoid. 



PARALYSIS OF THE LARYNX. 373 

The prognosis, in all these forms of paralysis, is favorable pro- 
vided we can place the patient under proper conditions. 

The first indication is to secure rest for the larynx; in the second 
place, to remove the cause of the affection if it can be discovered. 
Electricity, by means of faradism or galvanism, may be used every 
day for ten or fifteen minutes, one electrode being placed within 
the larynx, the other externally. The general health should receive 
attention and the use of tonics, exercise, full diet and strychnia 
to its physiological effect, will assist recovery. 

The most common form of paralysis of the vocal bands due to 
nerve lesion is recurrent laryngeal paralysis, which is traced, in a 
large proportion of cases, to pressure upon the recurrent laryngeal 
nerve at the root of the neck by aneurysm of the arch of the aorta, 




Fig. 144. — Partial Paralysis of Right Recurrent during Respiration. 

by enlarged lymphatic glands, mediastinal tumors, or esophageal 
growths, or by pleuritic adhesions at the apex of the lungs in 
tuberculosis. The last mentioned cause is met with more fre- 
quently upon the right side than upon the left. A central lesion from 
cerebral apoplexy, embolism, or occurring in the course of locomotor 
ataxia, may lead to similar phenomena. The neuritis following diph- 
theria or typhoid fever may also result in paralysis of the inferior 
laryngeal nerve. In this condition the cord affected assumes the 
cadaveric position midway between abduction and adduction, the 
apex of the arytenoid being tilted forward. The unaffected cord 
crosses the middle line in phonation to meet the opposite cord, the 
sound arytenoid passing in front of the paralyzed arytenoid, giving a 
very distorted laryngeal picture. The loss of voice is usually not 
very marked, complete aphonia being the rule only when both 
recurrent nerves arc affected. Paralysis of one nerve usually 
develops slowly and, as it progresses, the opposite cord has time to 



374 DISEASES OF THE NOSE, THROAT AND EAR. 

compensate for the loss of action on the part of the paretic vocal 
band (Fig. 144). 

The prognosis of recurrent laryngeal paralysis depends upon the 
location of the disease and upon its duration. When it has existed 
for many months degenerative changes may have occurred in the 
muscles which cannot be overcome (Fig. 145). 

The treatment should be governed bv the nature of the cause of 




Fig. 145. — Partial Paralysis of Right Recurrent during Phonation. 

the affection. Post-diphtheritic cases recover under tonic doses of 
strychnia and the use of electricity. These methods, of course, 
should not be used in cases of paralysis due to aneurysm or to pres- 
sure upon the trunk of the nerve, although there is no objection to 
exercising the intrinsic muscles of the larynx by means of the faradic 
current if there is any hope that the function of the nerve may be 
eventuallv restored (Fig. 146). 




Fig. 146. — Complete Right Recurrent Paralysis on Phonation. 

A lesion of the superior laryngeal nerve results in complete anes- 
thesia of the laryngeal mucosa as well as in paralysis of the crico- 
thyroid and occasionally in paresis of the arytenoideus, in some cases 
the superior laryngeal nerve sending a few motor fibers to the latter 
muscle. The loss of sensation is sometimes an important feature 
necessitating artificial feeding, since anesthesia of the larynx may 
lead to inspiration of particles of food which would not be promptly 
rejected. 



PARALYSIS OF THE LARYNX. 375 

The laryngeal picture has been referred to in speaking of paralysis 
of the arytenoideus muscle, the only parts of the vocal bands in con- 
tact being the vocal processes, an elliptic opening remaining an- 
teriorly and a triangular opening posteriorly during phonation. A 
large proportion of these cases result from diphtheria. 

Recovery may be spontaneous in the course of a few months or 
may be deferred a year or more, but it is expedited by judicious 
treatment, counter-irritation, stimulation with electricity, massage 
and tonics. In this, as in most other forms of paralysis, care should 
be taken to avoid overuse of the voice and all intercurrent inflam- 
matory conditions should receive attention. 




Fig. 147. — Partial Paralysis of Posterior Cricoarytenoids during Respiration. 

Paralysis of the abductors, or posterior cricoarytenoid muscles, 
may be bilateral or unilateral. The most frequent cause of bilateral 
abductor paralysis is a syphilitic lesion involving the special nerve 
center. It may occur in locomotor ataxia. Again, it may be due to 
lesions in the course of the nerve, such as neoplasm, aneurysm, or 
goitre. It may occur in lead-poisoning and is said to follow toxemia 
from various other chemical poisons (Fig. 147). 

The dyspnea resulting from this condition comes on by degrees 
and is inspiratory. It is distinctly progressive, is aggravated by 
exertion or excitement and may become at any moment of serious 
import. Expiration is less affected and the voice is unchanged 
except, perhaps, being slightly weaker than normal. 

In the mirror, the image on phonation is unaltered; but, during 
respiration, the cords are seen lying near together in the middle line 
instead of being abducted. 

The treatment depends upon the cause discovered. If of syphi- 
litic origin the disorder may be remedied by the administration of 
iodide of potassium, pushed to its fullest extent, at the same time, 
the muscular tone being preserved by means of electricity. The 



376 DISEASES OF THE NOSE. THROAT AXD EAR. 

possibility of sudden laryngeal stenosis should be kept in mind 
and the probable necessity of intubation or tracheotomy. The latter 
is preferred. In a case of my own in which the paralysis followed 
extirpation of a goitre, an intubation tube was worn for a short 
time but became so irksome to the patient that she insisted upon 
the trachea tube being introduced. The obvious advantage of the 
latter is that with the trachea tube in situ the patient is still able to 
phonate. which is not the case with an intubation tube. Sudden 
death occurring in a tabetic may be due to ischemia of the respira- 
tory center in the medulla rather than laryngeal obstruction. Here 
inversion of the patient and artificial respiration are demanded. It 
has been proposed in inveterate cases of bilateral abductor paralysis 
to split the larynx and excise the paralyzed cords, a radical mode of 
treatment which has not received universal acceptance. Section of 
the recurrent laryngeal nerves which would result in placing the 
cords in the cadaveric position and. at the same time, abolish the 
voice, has been suggested by Krause. Section of the nerve of one 
side only might be expected to give adequate breathing space without 
destroying the voice. Unfortunately the object is defeated by fixa- 
tion of the cricoarytenoid joint, or by shortening of the adductors, 
a result of long unopposed contraction, which still holds the cords 
in the middle line. 

Unilateral paralysis of the abductor may be due to causes similar 
to those acting in the case of bilateral paralysis, except that it has 
never been known to follow a central lesion. The voice is preserved 
and nothing anomalous is to be seen in the mirror during phonation, 
but on inspiration the affected cord occupies the middle line, while 
the sound cord is abducted in a normal way. Active treatment is 
seldom called for. except in syphilis, since the symptoms are usually 
unimportant. 

The preponderance of abductor over adductor paralysis has led to 
the enunciation by Felix Semon of a law ascribing to the posterior 
cricoarytenoid muscles, the only abductors of the vocal bands, an es- 
pecial vulnerability, in consequence of which adduction of the cords is 
the phenomenon first noticed in general laryngeal paralysis. The 
question has been hotly discussed. Recent investigations by Gross- 
man seem to show that after division of the recurrent nerve the vocal 
bands assume a median position for a few hours or days, as the case 
may be, gradually becoming cadaveric. The primary position in 



PARALYSIS OF THE LARYNX. 377 

adduction he explains by temporary action of the cricothyroid and 
the external muscles which,' of course, are not affected by abolition of 
the function of the inferior laryngeal nerve. This view, however, 
drawn from experiments on the cat, is opposed by the best authorities 
who find that in human beings the bands at once become cadaveric 
on section of the recurrent. A possible explanation of a posticus 
vulnerability may be found, as suggested by Grabower, in a peculiar 
difference in the way in which the nerve terminates in the abductors 
and in the adductors, in the latter its endings being broader and 
firmer. Hence we might expect the innervation of the adductors to 
be more vigorous and resistant than that of the abductors. What- 
ever explanation of the fact may be offered the majority of observers 
agree that under electrical stimulation the laryngeal adductors 
exhibit more vitality than the abductors. In studying the innerva- 
tion of the larynx confusion is apt to arise from the fact that the 
nerves of either side may cross to supply the muscles of the opposite 
side. Moreover, many observations have established the fact that 
motor fibers from the superior laryngeal nerve sometimes pass to the 
adductor muscles. The whole question is so intricate and opportuni- 
ties for observing paralysis of the larynx are so rare that a final 
solution of the problem has not been reached. 

In relation to the question of laryngeal paralysis it may be of 
service to keep in mind the following propositions. 

1. All intrinsic muscles of the larynx are attached to the arytenoid 
cartilages, except the cricothyroid. 

2. The cricothyroid arises from the thyroid cartilage and is in- 
serted into the cricoid, hence in contracting it pulls up the anterior 
border of the latter, tilts the arytenoids backward and makes tense 
the vocal bands, in the meantime the thyroid cartilage being immova- 
bly fixed by the action of the external muscles, the sternothyroid and 
the thyrohyoid. 

3. The superior laryngeal nerve is the sensory nerve of the larynx, 
but sends motor fibers to the cricothyroid muscle and sometimes to 
the arytenoideus. 

4. The inferior, or recurrent, laryngeal nerve gives motor fibers to 
all the intrinsic muscles, except the cricothyroid. 

5. Nerve fibers in the vagus supplying antagonistic muscles run in 
separate bundles throughout the length of the recurrent nerve. 

6. Adjacent cortical centers at the lower end of the ascending 



;;5 DISEASES OE THE NOSE, THROAT AXD EAR. 

frontal convolution exist for both the adductors and the abductors 
and are bilateral in action. Hence bilateral spasm of the larynx fol- 
lows irritation of the cortical center of either side, that of the adduc- 
tors predominating because of the greater strength of these muscles. 
Owing also to the bilateral action of the cortical centers laryngeal 
paralysis seldom results from a unilateral cerebral lesion. 

7. In progressive disease affecting the innervation of the larynx 
the abductors are the first to succumb to paralysis and atrophy. If 
recover}* takes place the reverse course is pursued and the adductors 
are hrst to regain tone. 

8. In complete recurrent paralysis the vocal bands at once assume 
a cadaveric position, midway between adduction and abduction. 

It is desirable but often quite impossible to differentiate between 
paralysis of the vocal bands and anchylosis of the cricoarytenoid 
articulation. Disturbance in the joint may follow exposure to cold. 
infection, rheumatism, tuberculosis, or traumatism. A feeling of 
discomfort or of slight pain on swallowing or when lying down may 
be complained of. It is difficult for the patient to locate the sensa- 
tion but it may be defined by palpation over the cricoid in the 
neighborhood of the joint. The pain is to be distinguished from 
that present in an aggravated degree of hyperesthesia of the superior 
laryngeal nerve by the fact, affirmed by Griinwald, that in the latter 
pressure must be applied at "the upper lateral border of the thyroid 
at its center." In some cases crepitation is detected. In the 
laryngeal mirror nothing abnormal is seen until periarthritic swelling 
supervenes. The movement of the vocal band on the affected side, 
instead of being smooth and gliding, is uneven and jerky, or the 
excursion of the band on attempts at phonation is incomplete or 
entirely absent. If the band is fixed in a position simulating that of 
one of the forms of paralysis it is possible to make a diagnosis only 
by excluding the probable causes of disturbed innervation. In 
most cases of anchylosis there is more or less permanent thickening 
about the joint, which is not a feature of paralysis. A position of a 
vocal band unlike that of a neurosis, a jerky movement of the band 
on phonatory efforts, and finally variable motility, or in other words 
more freedom of motion at one time than at another, are presump- 
tive evidence of cricoarytenoid arthritis, The case is strengthened 
by a distinct history of rheumatism, of syphilis, or of tuberculosis. 
The greatest difficulty arises in connection with cases of complete 



PARALYSIS OF THE LARYNX. 379 

fixation of the cricoarytenoid joint without thickening. A most 
important point, especially noted by Watson Williams, is the relation 
to each other of the arytenoids. Their relative positions in paralysis 
have been described: in anchylosis the sound arytenoid on phonation 
does not cross the crippled one, pushing it aside, but merely crowds 
up against it without displacing it. In certain old cases of paralysis 
the joint may become anchylosed from disuse, so that the point last 
mentioned is not invariably reliable. 



CHAPTER XXIV. 

FOREIGN BODIES IN THE LARYNX. PROLAPSE OF THE VENTRICLE. 

FRACTURE OF THE LARYNX. 

FOREIGN BODIES IN THE LARYNX. 

The subject of foreign bodies in the larynx carries the laryngologist 
somewhat beyond the limits of his territory, since in many cases a 
body supposed to have entered the larynx is found not in that cavity, 
but in the pharynx, the trachea, or a bronchus. It will be conve- 
nient, therefore, not to confine this consideration strictly to the 
larynx. 

The importance of a foreign body in the larynx depends upon the 
shape and size of the object and upon its point of lodgment. Fatal 
asphyxia may follow the inspiration of a very large body, whereas 
a small sharp-pointed object, like a fish-bone, pin, or piece of glass, 
may not interfere seriously with the air current. An object with 
rough, irregular surfaces is much more apt to be caught in the laryn- 
geal cavity than one with a smooth surface. A glass bead, for exam- 
ple, is likely to slip through the glottis, lodge in a bronchus and 
become the source of very serious mischief. A case which attracted 
great attention several years ago was that of a well-known clergyman 
who inhaled a cork he was holding between his teeth (Rushmore). 
The body passed directly through the larynx and lodged in a bron- 
chus. Efforts to remove it through an opening in the trachea were 
unsuccessful and death from pneumonia finally ensued. The 
feasibility of reaching the foreign body in cases of this kind by a 
bronchotomy done from behind has been suggested. Almost any 
object that the mouth can hold is liable to be drawn into or toward 
the glottis so as to impede respiration. Children particularly have 
a fashion of putting everything in the mouth; whence, in deep inspira- 
tions preceding laughing or coughing there is danger of the foreign 
body being sucked into the lower air-tract. 

Usually the signs of invasion of the larynx by a foreign body are 
unmistakable; but, it is remarkable that one, even of large dimen- 

380 



FOREIGN BODIES IN THE LARYNX. 38 1 

sions, under some circumstances, may be retained for a considerable 
time without producing much disturbance. Several years ago I 
reported a case of tooth-plate, which fell into the larynx during a 
puerperal convulsion and was not discovered until one week later 
when the patient complained of sore throat. Lennox Browne, a few 
years ago, recorded a case in which a plate of artificial teeth was 
impacted in the larynx twenty-two months before it was recognized. 
S. W. Langmaid once removed a pin from the larynx two years 
after it had been inhaled, in the meantime hoarseness being the only 
symptom. Johnston's famous case of a toy locomotive, impacted 
in the larynx and removed several months after a tracheotomy for 
relief of the immediate symptoms, is probably unique. 

In a large proportion of cases collected by Durham spontaneous 
expulsion took place in from one to seventeen years, and Gross 
records a case in which a piece of bone was retained in the air pas- 
sages for more than 60 years. Cameron's case of a penny in the 
larynx for six years, and Cohen's two remarkable cases in which a 
foreign body, one of them a pebble stone, remained in the air-tract 
for ten years without doing much damage, are noteworthy. From 
a thorough study of this point Wood concludes that spontaneous 
relief may be expected in about 57 per cent, of cases. In spite of 
this rather favorable showing and in view of the success attending 
modern methods of operating, the opinion of Weist that a patient 
with a foreign body in the trachea or a bronchus is more likely to 
recover if let alone is not shared by the majority of surgeons. The 
extension to the trachea and bronchi of Kirstein's plan of direct 
inspection has doubtless been the means of rescuing many a des- 
perate case. Manipulations under guidance of the eye are beyond 
question more precise and effective than blind groping with forceps 
or probe. 

In striking contrast to the tolerance displayed in cases like those 
just mentioned is the violent and prolonged spasm often excited by 
a drop of water or a crumb of bread which may barely get into the 
larynx in that unpleasant phenomenon known as "swallowing the 
wrong way." Occlusion of the trachea has been known to follow the 
escape of caseous material from an ulcerating bronchial gland, and 
vomited matter not infrequently finds its way to the larynx, espe- 
cially in the newborn, in weaklings, in alcoholics and during anes- 
thesia. Numerous instances of lumbricoids in the larynx, many oi 



382 DISEASES OF THE NOSE, THROAT AND EAR. 

them fatal, have been recorded, and the introduction of leeches in 
drinking water seems to be a not uncommon accident in certain coun- 
tries. A single instance in which the tip of the epiglottis curled back 
and became engaged in the rima glottidis so as to induce dangerous 
symptoms has been recorded by Ruehle. Cases in which an elon- 
gated uvula has not only irritated the larynx but caused serious em- 
barrassment to breathing have come under my observation. In one 
in particular the patient was supposed to have edema of the glottis. 
Several cases in which the fragment of a broken dental or surgical 
instrument has fallen into the larynx have been reported, and no less 
than twenty examples of broken or corroded trachea tubes dropping 
into the windpipe are to be found in literature. When a foreign 
body finds its way still lower in the air tract it is almost sure to get 
into the right bronchus owing to the fact that the division between 
the bronchi is to the left of the median line. According to Poulet, 
another reason is the greater force in the current of air going to 
the right lung with its relatively larger capacity. 

The first symptom excited by a foreign body in the larynx is a 
paroxysm of coughing which, in some cases, is successful in expel- 
ling the intruder. Spasmodic contraction of the muscles in violent 
efforts at coughing may, on the other hand, drive a sharp-pointed 
body into the wall of the larynx where it will remain until removed 
by artificial means. Hemorrhage may be excited by a body of this 
character. Bosworth narrates an unusual case in which repeated 
attacks of hemoptysis were apparently caused by a calcareous mass 
resembling a tooth lodged in a bronchus without giving any physical 
signs. The bleedings ceased after the foreign body had been expelled 
by coughing. In all cases in which the accident is suspected attempts 
at laryngeal examination should be made but, owing to the perturba- 
tion of the patient, it is often impossible to get any view. Under 
these circumstances it often happens that a mistaken diagnosis is the 
result. The symptoms have been attributed, in some cases, to croup 
or whooping-cough. In a very extraordinary case referred to by 
DeForest Willard a tracheotomy was done and prolonged search 
made for an article afterward found in the child's pocket, certain 
lung symptoms which were present being due to a pneumonia devel- 
oping from ordinary causes. 

In a case of my own in which the voice was lost and no other 
symptom was present after the first disturbance the electric current 



FOREIGN BODIES IN THE LARYNX. 383 

was applied to the larynx for more than a week with the hope of 
restoring the lost vocal function; at the end of that time a laryngeal 
examination discovered, lodged in the ventricle of the larynx near 
the anterior commissure, a shoe-hook. Six weeks later the boy was 
brought to my clinic where, after several ineffectual efforts at extrac- 
tion through the mouth, I performed partial laryngo-fissure and 
removed the hook. Recovery was complete and, in the course of 
six weeks, perfect use of the voice was regained. It is claimed 
that Kirstein's method of examining the larynx in children under 
these circumstances, is particularly successful. An almost identical 
case has been reported by E. Fletcher Ingals, but in the latter the 
foreign body was pushed upward by means of a Trousseau tracheal 
forceps and then extracted with the finger passed into the mouth. 

In every case, unless the symptoms be urgent, in which the pres- 
ence of a foreign body in the air-tract is suspected a careful laryngo- 
scopic examination should be made before attempts at removal are 
undertaken. In many cases a tracheotomy for relief of dyspnea must 
be done at once, and an examination made later. The precise loca- 
tion of a foreign body may be defined by means of the Roentgen 
rays when it cannot be discovered by inspection. Little or no reliance 
should be placed on the statement of a patient as to its situation, 
since subjective sensations are altogether misleading. It is a very 
common experience for a patient to point with confidence to the 
exact spot, where nothing can be detected except slight redness, or 
perhaps an abrasion or scratch made in transit by a foreign body 
which has been swallowed. These imaginary foreign bodies 
comprise a very large proportion of those which the surgeon is called 
upon to remove. On the contrary, a pin or a small fish-bone may 
become embedded in a lymph follicle at the base of the tongue, or in 
a tonsillar crypt, where it may readily elude a superficial search. 
Here the use of a probe to push aside folds of mucous membrane is 
often of service. Rough palpation with the finger is unwise, because 
a sharp object may be pushed still further into the tissues, or a 
movable one may be dislodged and fall into the larynx. 

The management of foreign bodies in the larynx demands the 
exercise of great ingenuity and dexterity. As examples of clever 
devices employed for their removal may be mentioned the electro- 
magnet in the case of metallic articles (Voltolini, Garel and Goul- 
lioud), a sponge after Voltolini's method ^Max Thorner) and cotton 



384 DISEASES OF THE NOSE, THROAT AXD EAR. 

wool wound on the end of the linger (Crawley) in the case of a 
cockle-burr in the larynx, and finally a brush dipped in mucilage to 
extract a thread (Brandeis). When the stenosis is due to spasm 
rather than to the volume of the object the inhalation of chloroform 
or the local use of cocaine is of advantage. An impacted body 
which interferes but slightly with breathing may be dealt with some- 
what deliberately. A smooth movable body is more dangerous 
because of its liability to shift its position and fall into a bronchus. 
A sharp-pointed or angular body, if roughly handled, may damage 
the wall of the larynx excessively, may even cause emphysema of the 
cellular tissue, or induce hemorrhage by penetrating a blood-vessel. 




Fig. 148. — Cusco's Laryngeal Forceps. 

It is sometimes necessary to break up and remove piecemeal an 
irregular object. A pin, lying in the larynx with point upward, 
must, if possible, be seized and pushed downward before any 
attempt is made to withdraw it. In adults, as a rule, the manipula- 
tions are conducted under local anesthesia with cocaine. In chil- 
dren, general anesthesia is not infrequently demanded. In young 
subjects, the interior of the larynx may often be reached by the tip 
of the finger. If the body is seated high up it may be removed by 
hooking the finger beneath it. In other cases we have to choose one 
of the various laryngeal forceps. Mackenzie's, or Cusco's (Fig. 148) 
or if preferred tube-forceps, or the cold-Avire snare is selected 
according to circumstances. If an unwarrantable amount of force 
is needed to dislodge an impacted body the alternative of external 
operation is presented. In the latter case we should hold before us 
the importance of preserving the function of the larynx by accurate 
replacement of the vocal bands, an object not easy of accomplish- 



FOREIGN BODIES IN THE LARYNX. 385 

ment if section of the thyroid cartilage has been complete. To 
secure perfect apposition of the halves of the larynx it is well, 
therefore, to leave the upper margin of the cartilage undivided. 
This mode of procedure, especially in young subjects in whom 
the parts are pliable, does not interfere with a satisfactory exposure 
of the interior of the larynx. In order to prevent reflex inhibition 
of heart action applications of cocaine to the mucous membrane 
both before and during a fissure of the larynx are recommended, 
and great care should be taken to keep the incisions in the middle 
line. 

Since the technical details of tracheoscopy and bronchoscopy 
have been brought so near perfection by Killian, Bruenings and 
Chevalier Jackson, the necessity of an external operation for removal 
of a foreign body is well-nigh abolished. In young children owing 
to narrowness of the air-tract and the danger of provoking edema 
of the glottis, and when the foreign body is caught at a remote point, 
it is judicious to select a low bronchoscopy, the tube being passed 
through a tracheal opening. By upper bronchoscopy, the tube 
being introduced through the larynx, it is often possible to reach 
even the secondary divisions of the bronchi. Essentials to success 
are (i) thorough anesthetization, local in adults, general in children, 
(2) tubes of proper shape, length, and caliber, (3) good illumination, 
and (4) suitable extracting instruments. Various modifications 
are required depending on the size, form and location of the object 
to be removed. In many cases these points are positively deter- 
mined by the skiagraph. The source of light is most important. 
In the Killian-Bruenings' instrument the light is at the proximal 
end and the rays are projected along the tube by an ingenious 
arrangement of magnifying lenses. This mechanism has been 
modified by Jackson (Fig. 149), who has placed a lamp at the 
distal end of the tube, by which more brilliant illumination with 
less waste of light is secured and manipulations are much simplified. 
It is interesting to note that statistics gathered by Coolidge show a 
mortality of only 8 per cent, in bronchoscopy operations, as com- 
pared with 22 per cent, by other methods. 

The use of emetics and experiments with inversion in children 

should not be resorted to unless we are prepared to open the trachea. 

since the foreign body may be propelled from below to a position in 

wdiich it may completely block the lumen of the larynx. This 

25 



386 DISEASES OF THE NOSE, THROAT AND EAR. 




Fig. 149.— Chevalier Jackson's bronchoscope with slanting end to 
facilitate introduction. 




Fig. 149 a— Separable speculum for passing bronchoscopes. The detachable 
handle (A B) is needed for locally anesthetized patients in the sitting position or 
when the speculum is held by an assistant. (D.B. Kyle.) 

The reader is referred to Chevalier Jackson's work on Tracheo-Bronchoscopy for 
complete information as to manipulative details. 



FOREIGN BODIES IN THE LARYNX. 387 

especially applies to a body known to be jagged or irregular in con- 
tour. If it has passed beyond the larynx Weist advises never to 
try inversion without a preliminary tracheotomy. If the trachea 
must be opened it is well to enter at as low a point as possible, to 
make a long incision and possibly to resect a part of two or more 
tracheal rings in order to provide for easy exit of the foreign body in 
case it should be dislodged by coughing. The method of inversion 
proposed by Padley is applicable to adults and comparatively free 
from danger. The patient is made to lie on his back with his knees 
flexed over the end of a bench which is considerably higher than the 
opposite end. He should inspire deeply and not attempt to speak. 
Forcible concussion of the chest sometimes helps to dislodge the 
foreign body. The supine position favors its escape and should it 
impinge upon the chink of the glottis the patient is readily able to 
resume an upright posture. In Roe's collection of seven hundred 
and sixty-three cases of foreign bodies in the air-passages we find 
only three relieved by inversion and six by emesis when the larynx 
was involved, while nine recovered after inversion and two after the 
use of emetics when the substance was in the trachea. From an 
analysis of the combined statistics of Weist (one thousand cases), 
Durham (seven hundred and six cases), Gross (one hundred and 
eighty-three cases), and his own, Roe concludes that a foreign body 
should not be allowed to remain in the air-passages for any length 
of time without operation in case attempts at extraction by other 
means have failed. When the larynx is occluded by a large foreign 
body, or by the spasm its presence excites, the trachea should be 
opened without delay, though the patient appears to be moribund or 
even dead. The discouraging opinion attributed to Louis that in 
cases of this kind we are helpless because no interval exists between 
perfect health and death seems to be unfounded, in view of the suc- 
cess attending artificial respiration and similar restorative measures 
in analogous conditions. A rapid tracheotomy followed by judicious 
and prolonged artificial respiration will sometimes save a case appar- 
ently desperate. Coins and flat objects that are apt to take a trans- 
verse position in the larynx are conveniently reached with Watson 
Williams' forceps. A coin in the esophagus has several times boon 
successfully extracted with Smith's coin-catcher. The ingenious 
instruments designed by W. C. Morton for use in direct bron- 
choscopy are well adapted to objects of this kind. Opposite the 



388 DISEASES OP THE NOSE. THROAT AND EAR. 

cricoid, the narrowest part of the gullet, a foreign body is most 
likely to be arrested. Coolidge once removed a foreign body from 
the right bronchus by passing an alligator forceps along a urethro- 
scope which had been introduced through a tracheotomy wound. 
The gradual solution of fish bones by means of vinegar and of meat 
bones by a dilute solution (1 to 5 per cent.) of hydrochloric acid 
has been suggested. A fish hook with its barbed point embedded 
in the tissues would seem to be almost impossible of removal by 
any internal method, but Christison's scheme of threading the wire 
attached to the hook through a hole drilled in the ball of a probang 
was highly successful in one case. Fortunately the wire had not 
been swallowed and it served as a guide to the bulb of the probang 
which latter so dilated the walls of the esophagus as to loosen the 
point of the hook and allow it to be withdrawn without catching. 
In the larynx a similar plan would not be feasible and an external 
operation would be the only alternative, either a subhyoid pharyn- 
gotomy or a laryngotomy. In a case in my clinic at Cornell 
Medical College a metallic heel plate was removed by Mack from 
the laryngopharynx of a shoemaker who was in the habit of holding 
these objects in his mouth while at work. Three sharp prongs 
projecting from the surface of the plate had to be disengaged by 
pressure with the finger, in the meantime traction being made on the 
plate which had been seized with canula forceps. Very little 
reaction followed, although the plate had been in the pharynx 
eight or ten hours, and had excited almost constant and irresistible 
desire to swallow. 

It is seen, therefore, that every case of foreign body in the larynx. 
or in neighboring regions, presents features peculiar to itself which 
must be met according to circumstances. 

PROLAPSE OF THE VENTRICLE OF THE LARYXX. 

Prolapse of the ventricle of Morgagni is a rare condition, very apt 
to be confounded with a new growth or with a simple inflammatory 
hyperplasia. It consists of protrusion of the sacculus laryngis as a 
result of sudden voice-strain or violent coughing, possibly in con- 
junction with atony or paresis of the muscle known as the com- 
pressor sacculi laryngis, or Hilton's muscle. In one case in my ex- 
perience a protruding mass simulating prolapse of the ventricle was 



FOREIGN BODIES IN THE LARYNX. 389 

excised, when it proved to be a tuberculous infiltration. Serious 
doubt as to the possibility of eversion of the ventricle was suggested 
long ago by Fraenkel and by Chiari. Moure believes that the 
condition of apparent prolapse is really one of chronic inflammation, 
and this view has received recent confirmation by Noack, who found 
that the tissues of a supposed everted ventricle were composed 
of vascular and edematous hypertrophies. It is maintained by 
Schroetter that an apparently prolapsed ventricle is in reality an 
example of chronic subglottic laryngitis, the thickened and projecting 
tissues giving the misleading impression of a tumor which seems to 
spring from the site of the ventricle. 

The treatment consists simply in replacement of the ventricle by 
means of a laryngeal probe and of faradization of the muscles of the 
larynx together with prohibition of the use of the voice for a consid- 
erable period. It may be found impossible to restore the prolapsed 
sacculus, in which case ablation would be the proper procedure, 
provided the subjective symptoms are very pronounced. 

FRACTURE OF THE LARYNX. 

Fracture of the larynx is a rare accident and may result from direct 
violence, as from a blow or by choking, from bullet wounds, or from 
muscular action during a violent paroxysm of coughing (Sajous). 
A large proportion of cases have been observed in early life, so that 
ossification of the cartilages incident to old age cannot be regarded 
as a predisposing factor. 

In most cases the thyroid alone is fractured, but in many the 
cricoid also is involved and in a few the hyoid bone is broken. 

External deformity is at once quite marked either as a depression 
or an unusual prominence of the thyroid, accompanied by more or 
less swelling of the external soft parts. If the mucous lining of the 
air-tract is lacerated hemorrhage may occur, and aphonia and cough 
with blood-streaked sputa are prominent symptoms. Dyspnea is 
present early or not for several days after the accident. Emphysema 
may be limited to the nieghborbood of the injury or may be diffused 
over the whole body, as in the case of a child six years old reported 
by Hume. The foregoing symptoms, together with crepitation 
on palpation, should establish the diagnosis. In severe cases 
when the cartilage is comminuted or the fracture is compound, but 



390 DISEASES OF THE NOSE, THROAT AND EAR. 

little doubt can exist. In simple cracks or linear fractures there is 
more difficulty. The prognosis in cases of the latter class is favor- 
able. A penetrating wound over the thyroid cartilage is dem- 
onstrated by blood-stained sputum and impairment of voice, the 
latter remaining permanent. 

In treatment the first indications are to replace distorted fragments 
and control inflammatory reaction by cold affusions. Swelling and 
edema may necessitate a tracheotomy or intubation. The latter is 
preferable, both with a view to supporting depressed fragments of 
cartilage and to preventing contraction of the air-tube during the 
process of repair. An O'Dwyer intubation tube as large as the 
larynx will accommodate should be selected and its introduction is 
facilitated by preliminary spraying with cocaine and suprarenal 
extract. In a case reported by W. K. Simpson a very large, some- 
what conical, tube was used which served as a dilator as well as an 
air-tube. In cases of extensive damage an intubation tube does not 
reach far enough and the only alternative is an opening in the trachea 
at the lowest possible point. 



THE EAR. 



CHAPTER XXV. 

ANATOMY, DEVELOPMENT, COMPARATIVE ANATOMY, EMBRYOLOGY. 

The temporal bone articulates with the sphenoid, parietal, 
occipital, inferior maxillary, and malar bones, and together with 
them forms the osseous framework of the temporal region. The 
outer and lower surfaces of this framework are covered with peri- 
osteum, and are in intimate relation with nerves, vessels, muscles, 
tendons, fasciae, glands, and cartilages, the whole being covered with 
an outer layer of skin. The inner and upper surface of this bony 
framework is covered by the dura mater which serves as periosteum 
and envelope for the brain. The bone supports the temporo- 
sphenoidal and occipital lobes of the cerebrum and the cerebellum, 
forming the lateral protection of the cerebellum and cerebrum, as 
well as supplying an anterior wall for the cerebellum. Important 
nerves, veins, and arteries are brought into contact with these 
surfaces. This region is of great anatomical interest and of vital 
importance structurally, physiologically, and pathologically. 

For convenience the ear may be divided into the conventional 
outer, middle, and inner ear. 

The outer ear is the sound-collecting mechanism, and includes the 
most external part of the ear, the auricle, and the passage which 
leads to the drum — the external auditory canal. 

The auricle, or pinna, consists of an irregularly crumpled plate of 
cartilage enveloped in perichondrium and covered with skin, which 
is closely adherent to the perichondrium in front and separated 
from it behind by loose areolar tissue. The lobe or appendage of 
the auricle is a fibrous network containing fat. The cartilage of the 
auricle is continuous with the cartilage of the auditory canal and is 
attached to the osseous canal. Sebaceous glands are abundant in 
the lobe and in the anterior surface of the auricle, especially in 
the concha or hollow of the ear. These glands are also found 
below and behind the auricle. 

39i 



39 2 



DISEASES OF THE NOSE, THROAT AND EAR. 



The corrugations of the surface of the auricle are sustained by 
fibrous adhesions of the perichondrium. The angle which the 
auricle makes with the side of the head is due to the adhesion of 
the posterior perichondrium with the post-aural periosteum. 

The external auditory canal (or meatus auditorius externus) 
is an irregular tube, slightly compressed anteroposterior^, with a 
varying amount of angular curvature; it is composed of two nearly 
equal portions — the outer cartilaginous, and the inner osseous. The 
cartilaginous walls of the canal are continuous with the cartilage of 



SUPERIOR CRUS OF HELIX 



FOSSA 
INTERCRURALIS 



INCISURA 
INTERTRAGICA 




LOBE 

Fig. 150. — Left Auricle. 



the auricle. There are several fissures in the cartilaginous part of 
the canal called fissures of Santorini, through which pus may burrow. 
The canal extends inward from its mouth, backward and upward; it 
then turns forward, still proceeding inward, to the junction of the 
cartilaginous with the osseous portions of the canal. At this point 
it again turns backward in a curve; finally, at the extreme inner end 
it curves forward and downward. The inner end enlarges some- 
what, leaving a slight isthmus near the drum membrane. The upper 
surface at this point is slightly vaulted. The antero-inferior wall, 
at its inner end, combines with the drum membrane to form a pouch, 



THE OUTER EAR. 



393 



which lies beyond an elevation of the floor of the canal near the 
drum membrane where the isthmus of the canal is located. The 
antero-inferior wall is convex; the postero-superior wall, concave. 



FOSSA SCAPHOIDEA 



F055A INTERCRURALIS 



UPPER PART CONCHA — ? 




OSSEOUS CANAL 



LOWER PART CONCHA 



EDGE OF 
TYMPANIC MEMBRANE 



2 NO BEND 
OUTER AUDITORY CANAL 



Fig. 151. — Cast of Right Auricle and Canal Cavities Viewed from Within. 

The canal is terminated by the drum membrane which lies obliquely 
across the end. Owing to this oblique position of the drum 
membrane, the antero-inferior wall of the canal is much longer than 

FROM BELOW AND BEHIND FROM BELOW AND BEHIND FROM BELOW AND BEHIND" FROM BEHIND FROM ABOVE FROM BELOW AND BEHIND 
60° TO HORIZON 45° TO HORIZON 20° TO HORIZON 75° TO HORIZON 




Fig. 152. — Outline of Cast of Right External Auditory Canal 



the postero-superior, being 35 mm. and 29 mm. in the adult 
respectively. 

The cartilaginous portion of the canal is supplied with ceruminous 
glands and hairs. Its anterior wall rests upon the outer half of 



394 



DISEASES OF THE NOSE, THROAT AND EAR. 



the maxillary articulation and is subject to forward traction, back- 
ward movement and compression, as the jaws are opened or closed. 
The osseous part of the canal has a rigid wall lined with a thin 
dermoid layer devoid of glandular structures, and closely adherent 
to the periosteal covering of the bone. This lining is slightly thicker 
along the superoposterior wall and around the attachment of the 
drum membrane. A vascular network lies in these localities and 
passes down along the handle of the hammer. 



SUPRA MASTOID RIDG 



GROOVE TEMPORAL ARTERY 

POSTERIOR ROOT ZYGOMA 



MIDDLE ROOT ZYOOMA 

ANTERIOR ROOT ZYGOMA 



PARIETAL 
BONE 



MASTOIDEO- 

3QUAMOSAL 

SUTURE 




GLASERIAN FISSURE. 
AUDITORY PROCESS 



MASTOID FORAMEN 

MASTOII 



TYMPANIC PLATE 
VAGINAL PROCESS 

STYLOID PROCESS 

EXT. AUDITORY MEATUS 



TYMPANIC FISSURE 



Fig. 153. — Outer Surface of Right Temporal Bone. 



The inferior, posterior, and anterior walls of the osseous canal 
are formed by the auditory plate, developed from the tympanic ring 
(annulus tympanicus) and extending outward from the sulcus tym- 
panicus. The lower wall of the canal forms the base of the vaginal 
process of the petrous bone, and terminates externally in the 
auditory process for the attachment of the cartilaginous portion of 
the canal. The anterior wall forms the posterior wall of the glenoid 
fossa up to the fissure of Glaser. The free external border of this 
wall serves for the attachment of the cartilaginous canal. The 
posterior wall covers the anterior aspect of the mastoid cells and 
mastoid antrum. The junction of the auditory plate with the 
mastoid portion of the temporal bone is marked inferiorly and 



THE MIDDLE EAR. 



395 



externally by the auditory fissure; the superior wall is formed by the 
horizontal plate of the squamous portion of the temporal bone. The 
inner end of this wall acts as the upper, outer boundary of the cavum 
tympani, or drum cavity, and the outer and lower wall of the niche of 
the attic or epitympanum. The spine of the meatus is placed at the 
external posterior edge of this wall. The posterior root of the 
zygoma forms the upper lip of the osseous canal. The middle 
fossa of the skull and the temporo- sphenoidal lobe of the brain lies 
above the superior wall of the canal and is separated from the canal 
by a thin bone of varying thickness, with or without air-cells. The 
inner part of the posterosuperior wall of the canal is the anterior 
wall of the mastoid antrum, and is quite thin because of the approxi- 
mate parallelism of the antrum and auditory canal. 



CELL3 LEADING 
FROM ANTRUM 


ADITUS AD 

/-— Ql antrum 


DEPRESSION FOR BODY OF 
MALLEUS AND INCUS 


LOWER CELLS MASTOID Y 
PROCESS S^ 






EPITYMPANUM 
|p>f TYMPANIC MOUTH OF TUBE 

Rj^fv/ /OSSEOUS TUBE 




|y fffW^^C 




ANTRUM &5F Jy^^^vV 




MEMBRANA TYMPANI^^/ /^|K CARTILAGINOUS TUBE 
WITH GROOVE OF MALLEUS " / ^^^NtV / 
ISTHMUS ^TNy 




LOWER PART \-JSn^ PHARYNGEAL 
TYMPANIC CAVITY ^^.^-v^MOUTH OF TUBE 
^X& \ 1 CLOSED 



Fig. 154.— Metallic cast of Right Middle Ear Tract Viewed from the Outer Side. 



The middle ear is the mechanism for the transmission of the 
sound already collected by the external ear to the inner ear, where 
the peripheral sound-perceiving apparatus is located. The middle 
ear consists of an irregular tube leading from the side of the naso- 
pharynx. The axis of the tube lies at an angle of 45 ° to the three 
planes of the body — anteroposterior, sagittal, and horizontal. In 
mechanical construction, the middle ear resembles a drum, the 
tympano-pharyngeal, or Eustachian tube corresponding to the air- 
hole in the side of the drum, and the drum membrane to the drum 
head. 

The main axis of the middle ear or drum corresponds to the 
axis of the tympano-pharyngeal tube which runs outward 45 , up- 
ward 45 , and backward 45 . The drum has but one natural 



396 DISEASES OF THE NOSE, THROAT AND EAR. 

opening and this is through the tympano-pharyngeal tube. The 
drum and the external auditory canal are separated only by a thin 
membrane, the membrana tympani or drumhead. 

The middle ear is divided, for pathological reasons and for 
convenience in anatomical description, into three parts: 1. The 
tympano-pharyngeal tube. 2. The cavum tympani, or drum proper, 
composed of the atrium, the part below the drum membrane, and 
the epitympanum or attic, the part on the inner side of the drum 
membrane. 3. The mastoid portion, consisting of the aditus 
ad antrum or passageway to the antrum, the antrum itself, and the 
mastoid cells. 

The tympano-pharyngeal, or Eustachian tube, connects the cavum 
tympani with the naso-pharynx. It presents a flaring internal 
or pharyngeal orifice, and a flaring external or tympanic orifice, 
with a contraction or isthmus at the junction of the cartilaginous 
and osseous portions of the tube. The tube runs from the side of 
the naso-pharynx outward, forward, and upward at an angle of 45 . 

The pharyngeal orifice of the tympano pharyngeal tube is 
located at about the same level as the posterior attachment of the 
inferior turbinate, and its anteroposterior position is about abreast 
of the posterosuperior angle of the vomer. The tube measures 
on the average 40 mm. along its anterior wall to the sulcus tym- 
panicus. The inner 30 mm. are cartilaginous; the remaining 10 
outer mm. nearest the membrana tympani, are osseous. The 
maximum diameter of the isthmus is, on the average, 4 mm.; the 
minimum diameter, which is horizontal, may be as small as 2 mm. 
The surface of the osseous part of the tube is not smooth; its walls 
may present small bony ridges and, at the tympanic orifice, bony 
spiculae may jut into the lumen, thereby decreasing the diameter 
and obstructing a direct passage. The mucous lining of the tube is 
continuous centrally with the pharyngeal mucosa, and peripherally 
with the mucous lining of the cavum tympani. This mucous lining 
is composed of three layers: First, the ciliated columnar epithelium; 
next, a layer of lymphoid tissue; and third, a glandular layer. The 
layers are separated by elastic fibrous tissue. The lymphoid 
follicles are more abundant near the pharynx, where the membrane 
is thick and loose, than in the osseous portion, where it is thin, 
smooth and closely adherent to the periosteum. 

The pharyngeal end of the osseous tube shows a jagged orifice 



THE MIDDLE EAR. 397 

with the greatest diameter vertical; its upper wall is formed by 
the canal of the tensor tympani muscle; its inner wall by the carotid 
canals; and the outer wall by the spinous process of the sphenoid 
bone, and foramen spinosum for the middle meningeal. Two 
large arteries lie close beside the upper wall of the osseous tube, 
which is a thin bony plate forming part of the middle fossa of the 




Fig. 155. — Pharyngeal Orifice of the Right Eustachian Tube at Rest. (View through 
a Eustachian salpingoscopy The fossa of Rosenmuller is seen on the left because the 
lenses reverse the image, a, fossa of Rosenmuller; b, torus tubae; c, mouth of tube, 
closed.) 

skull, and supporting the temporo-sphenoidal lobe The lower 
wall of the tube is the base of the inner half of the vaginal process 
of the petrous bone. The anterior wall is the posterior wall of 
the glenoid fossa. Its posterior wall is very thin; superiorly it is 
formed by the canalis pro musculo tensore tympani, and below by the 
anterior wall of the bend of the carotid canal. 



Fig. 156 — The same pharyngeal orifice of a Eustachian tube as in Fig. 6 during an 
act of swallowing. The upper surface of the soft palate occupies the foreground. The 
fossa of Rosenmuller is nearly closed by the backward and upward movement of the 
alar cartilage which has distended the tube, a, Fossa of Rosenmuller; b, torus tuba;; 
c, mouth of tube, opened; d, soft palate. 

The cartilaginous portion of the tube has for its posterior wall 
a plate of cartilage which has a nearly right-triangular posterior 
surface, and forms the greater part of the anterior wall of the fossa 
of Rosenmiiller or pharyngeal sinus. The apex of this triangle of 
cartilage lies at the junction of the cartilaginous with the osseous 
tube. The upper border of the cartilage is attached to the skull 
and fits into a depression on the sphenoid bone. The right angle 



398 DISEASES OF THE NOSE, THROAT AND EAR. 

of the triangle is situated at the pharyngeal end of the upper border 
of the cartilage, and is attached to the skull near the base of the inner 
pterygoid process. The inner border of the cartilage forms the 
short limb or vertical side of the triangle. The cartilage projects 
into the pharynx and is called the torus tubce. This border is also 
the free border of the cartilage and marks the pharyngeal entrance 
of the tube. The lower extremity of the free border ends in the 
angular process of the cartilage. The third and lower side of the 
triangle is freely movable. This triangular or alar cartilage passes 
above the tube and forms the hamular process, which turns down in 
front, and forms a small part of the anterior wall of the tube. The 
cartilage, which is made up of one large and several accessory plates, 
is elastic and contains clefts and holes. The greater part of the 
anterior wall of the tube is composed of strong membrane. 

The inferior wall of the open tube is a loose elastic sheet of 
fibrous tissue which contracts and folds together when the tube is 
closed. The lumen of the inner third of the tube is obliterated by 
the contact of the anterior and posterior surfaces when the tube is 
closed. The upper and lower boundaries of the external half of 
the cartilaginous tube are formed by the concavity of the alar 
cartilage. This part of the tube always remains open because the 
anterior wall does not wholly collapse against the concave posterior 
wall. The outer part of the tube, which normally is open, has a 
rigid and comparatively non-elastic wall, while the pharyngeal end 
is collapsible. When the tube is closed, the mucous membrane lies 
in longitudinal folds and forms reduplications or rugae, especially 
toward the pharynx and floor of the tube; but, when the tube is 
dilated, these rugae almost entirely disappear. The pharyngeal 
end of the tubal mucosa is thicker and richer in glandular struc- 
tures and lymphoid follicles than the rest of the tube. The long 
diameter of the closed pharyngeal ostium measures, on an average 
7 mm. ; the open ostium, an equilateral triangle, about 6 mm. (See 
Figs. 155 and 156 of pharyngeal mouth of tube.) 

Several muscles are situated on or in the neighborhood of the 
pharyngeal tube and affect it by their contractions. Chief of these 
are the retrahens tubce or levator palati and the tensor tympani. The 
fibers of both of these muscles run almost parallel to the long axis 
of the tube. The levator lies below the lumen of the tube and 
anterior to the angular process of the alar cartilage. It is attached 



THE MIDDLE EAR. 



399 



peripherally to the base of the skull on the petrous bone close to the 
entrance of the carotid canal. Sometimes the fibers are attached to 
the lower border of the alar cartilage. 

The tensor palati is a thin muscular and aponeurotic sheet, 
covering the anterior surface of the tube. It arises in a broad band 
from the sphenoid bone close to the outer side of the attachment 
of the cartilage of the tube. The direction of the muscular fibers 
varies from absolute parallelism with the tube to an angle of io° 
with it. 

The fossa of Rosenmuller, or the pharyngeal sinus, lies behind 
the tube in the superior posterior angle of the naso-pharynx. It is 
lined by the mucous membrane of the pharynx and is rich in lymphoid 




Fig. 157. — Shows the tube in cross-section. Two mm. of the pharyngeal extremity 
have been removed. The fibers of both the tensor and levator muscles are seen running 
parallel to the tube and are separated by the salpingo-pharyngeal fascia. The levator 
palati is seen resting on the anterior surface of the angular process of the cartilage. 
The levator palati has been drawn tense in the backward direction which it occupies 
when the soft palate is raised. It pushes the angular process of the cartilage upward 
and backward, encroaches upon the lumen of the fossa of Rosenmuller, and opens 
the tube. The anterior wall of the tube remains fixed. The increased circumference 
of the open tube is furnished by the elasticity of the tubal wall between the cartilage 
and the attachment of the salpingo-pharyngeal fascia, a, Fossa of Rosenmuller; 
b, section of tube, opened; c, cartilaginous portion of tube; d, levator palati; e, hamu- 
lar process of cartilage; /, membranous portion of tube; g, tensor palati; h, fascia 
between tensor and levator palati. 



tissue. It furnishes room for the movements of the alar cartilage 
which lies in its anterior wall. The cross-section of the fossa is 
somewhat lenticular in shape. Its upper angle is formed by the 
angle of attachment of the alar cartilage of the Eustachian tube to 
the base of the skull. Its lower commissure is formed by the 
upper border of the superior constrictor of the pharynx, or by the 
angle between the two slips of this muscle. The apex of the fossa 
reaches nearly to the lower orifice of the carotid canal. The posterior 
wall is supported by the prevertebral muscles. The depth of the 
fossa, measured along its anterior wall, is on the average t8 mm. 



4-00 



DISEASES OF THE NOSE, THROAT AND EAR. 



The distance from the upper to the lower commissure averages 26 
mm. When the Eustachian tube is closed, the width of the sinus 
averages 11 mm. 

The cavum tympani, or middle ear proper, is a disk-shaped space, 
inclined at 45 to the anteroposterior, sagittal, and horizontal axes 
of the head, and is larger in its wide diameters than the external 
auditory canal. It is divided into two compartments, the atrium 
or drum proper, and the epi-tympanum or attic. It contains the 
little ear-bones or ossicles, their muscles, tendons, and ligaments; 
the facial and the chorda tympani nerve, and numerous reduplications 
of mucous membrane. The walls of the cavum contain several 



EPITYMPANUM OR ATTIC 




Fig. 158.— Outer Half of Vertical Section of Middle Ear Tract Through Mastoid Antrum 

and Eustachian Tube. 

organs of especial importance and are of interest for many reasons. 
The walls are covered by a thin mucous membrane, or muco- 
periosteum, which is continuous with the mucosa of the tympano- 
pharyngeal tube. This membrane continues backward into the 
mastoid antrum and cells. The epithelium is columnar and ciliated 
in the lower part of the tympanum and flatter in the upper part. 
The mucous lining contains glandular elements which are more 
numerous in the anterior part, and disappear gradually posteriorly. 
The outer wall of the cavum is made up of the drum membrane 
or drum head with its bony frame, and the outer wall of the attic. 



THE MIDDLE EAR. 



40I 



The drum head, or membrana tympani, lies obliquely and leans 
forward, outward, and downward at an angle of 45 , forming the 
upper posterior surface of the inner end of the external auditory 



INCISURA R1VIN 




SULCUS 
TYMPANICUS 



MASTOID CELLS 



JUGULAR FOSSA FACIAL CANAL 

Fig. 159. — Vertical Section through Middle Ears hows Outer Wall of Cavum Tympani. 



canal. It is a tense, rigid, highly elastic membrane with an outward 
convexity. This convexity, however, is changed to a concavity at 
the center where the membrane is attached to the end of the handle 



HAMMER HANDLE 



CARTILAGINOUS 
SHEATH 



RADIATING FIBRES 




ANNULUS 
TYMPANICUS 



Fig. 160.— Diagram of Fibers of Membrana Propria of the Drum Membrane 



of the hammer or the manubrium of the malleus. At this point there 
is an umbilical depression, the umbo. The membrane lies tlat 
along its attachment to the rest of the hammer handle. The 
26 



402 



DISEASES OF THE NOSE, THROAT AND EAR. 



membrana tympani is made up of three layers, the outer dermoid 
layer being continuous with the lining of the external auditory canal. 
This layer contains blood-vessels and nerves and is covered by a 
layer of flat epithelium with a deeper layer of cylindrical cells. The 
inner, or mucous layer, is continuous with the mucous lining of the 
cavum tympani. It is covered with simple cuboid epithelium. 

The middle layer, or membrana propria, is composed of two sets 
of connective tissue fibers with very few elastic fibers, one set radiat- 



shrapnell's membrane 



5PINA TYMPANI 
POSTERIOR 



SPINA TYMPANI 
MAJOR 



SHORT PROCESS MALLEUS 



POSTERIOR FOLD 
OF MEMBRANE 



MANUBRIUM 



UMBO 




ANNULUS 
TYMPANICUS 



DRUM MEMBRANE 

Fig. 161. — Outer Surface of Left Drum Membrane (Enlarged). 



ing from the umbo and one concentric. The radiating fibers form 
the outer layer and are most abundant at the umbo, while the 
fibers of the concentric or inner layer are most abundant near the 
periphery of the membrane. The fibrous layer of the drum head 
is not of even thickness or strength. It is thinnest and weakest in 
its upper posterior quadrant and is altogether wanting in a small 
area at the upper margin of the drum head. This area is called 



THE MIDDLE EAR. 



403 



ShrapnelVs membrane, or membrana flaccida, in contrast with the 
rest of the drum membrane which is called vibrans. The membrana 
vibrans is attached peripherally to the annulus tendinosus or tendinous 
ring, which is itself fastened in the sulcus tympanicus of the bony 
tympanic ring or annulus tympanicus, forming the support or frame 
for the drum head. The drum membrane is attached by its mem- 
brana propria to a cartilaginous sheath which covers the anterior 
surface of the handle of the hammer. 



MEMBRANA TYMPANI 



CIRCULAR FIBRES 
■RADIATING FIBRES 



SKIN OF LOWER WALL OF 
EXT. MEATUS 




SULCUS TYMPANICUS 



Fig. 162.— Section of Attachment of Drum Membrane to the Sulcus 
Tympanicus (enlarged). 



The outer surface of the drum head shows the membrana vibrans 
attached to the outer surface of the handle of the hammer from the 
umbo where the membrane is attached to the tip of the handle, up 
to the short process of the hammer at the base of the handle. The 
short process of the hammer forms a slight protuberance on the 
surface of the membrane. From the end of the short process of the 
hammer, two faintly marked lines and two folds radiate in the 
membrane. The two lines lie above and are formed by small 
bands of fibrous tissue called Prussack's fibers } which run to the 



404 



DISEASES OF THE NOSE, THROAT AND EAR. 



anterior and posterior extremities of the annulus tympanicus. These 
extremities are the anterior and posterior edges of a rounded notch, 
the incisura Rivini. The fibers and the notch enclose the flaccid 
or Shrapnell's membrane. The two folds, called the anterior and 
posterior folds of the drum membrane, lie lower, one passing forward 
and one backward. They indicate a line of transition in the curve 
of the surface of the drum membrane between the vibrating and 
non-vibrating membranes. 



NICHE IN OUTER WALL 
TYMPANIC CAVITY 



SUSPENSORY 
LIGAMENT' 



BODY OF INCUS 

SHORT PROCESS 
INCUS 

SELLA INCUD15 



CHORDA 
TYMP. NERVE 




ANTERIOR 
LIGAMENT. 
MALLEUS \( 



CHORDA 
TYM. NERVE 



MANUBRIUM 
MALLII 



LONG 

PROCESS 

INCUS 



ANNULUS 
TENOINOSUS 



DK-.* MEMBRANE 



Fig. 163. — Inner Surface of Right Drum Membrane and Outer Wall 
of Attic (enlarged). 



The inner surface of the drum membrane shows the vibrating 
membrane with the handle of the hammer in bold relief. From the 
inner edge of the upper half of the posterior surface of the hammer 
handle, a web of membrane loops backward to be attached to 
the annulus tendinosus. Between this fold of membrane and the 
membrana vibrans lies the posterior pocket of the drum head. 
The apex of the pocket may be closed or open. If open, it connects 
with Prussack's space. A smaller fold of membrane extends from 
the upper end of the inner edge of the anterior surface of the handle, 
and runs along the lower surface of the anterior ligament of the ham- 



THE MIDDLE EAR. 



40; 



mer. Between this fold and the membrana vibrans a shallow 
pocket is formed which is called the anterior pocket of the drum 
membrane. This may also open superiorly. 

The nerve known as the chorda tympani is plainly seen crossing 
the tympanum. This nerve on its way forward emerges from its 
canal at the inner side of the sulcus tympanicus and forms the 
free edge of the posterior half of the fold of the posterior pocket. 
It then crosses the inner side of the neck of the hammer and disap- 
pears in its foramen of exit in the fissure of Glaser. 

The outer bony wall of the cavum tympani is continuous below 



DEPRESSION 
GLASERIAN 
GANGLION 



• PROMINENCE EXTERNAL SEMI-CIRCULAR CANAL. 
TEGMEN TYMPANI 

ADITUS AO ANTRUM 
■MASTOID ANTRUM 
TEGMEN ANTRI. 




EUSTACHIAN 
TUBE 

CAROTID CANAL 

OVAL WINDOW 

ROUND WINDOW 
SINUS TYMPANICUS 

JUGULAR FOS5A 

ROOT STYLOID PROCESS 

FORAMEN STAPEDU 



MASTOID CELLS 
STYLO -MASTOID FORAMEN 



Fig. 164.— Inner Wall of Left Middle Ear Tract, Vertical Section of Temporal Bone. 



with the floor; above, this wall bulges outward and forms a small 
shelf which overhangs the inner end of the external auditory canal, 
and is called the niche of the attic or epitympanum. Above this niche 
the outer wall joins the upper wall or tegmen of the cavum which 
is also the upper wall of the attic. In the center of the upper part 
of the tympanic margin of the outer wall of the cavum there is a 
little indentation in the floor of the niche of the attic called the 
incisura Rivini. In front, the outer bony wall of the cavum joins 
the anterior bony wall of the osseous tympano-pharyngeal tube. The 
posterior part of the outer bony ring of the cavum is continuous 
below with the posterior osseous wall of the cavum. Its upper half 
forms the outer wall of the aditus ad antrum mastoidal m. At 



406 



DISEASES OF THE NOSE, THROAT AXD EAR. 



this point the bony wall bends abruptly outward, running nearly 
parallel to the external auditor}- canal and forms the anterior wall 
of the antrum mastoideum. 

The internal wall of the cavum tympani is a bony barrier between 
the middle ear and the labyrinth or internal ear. The lower half 
of this wall forms the inner wall of the atrium and is occupied by a 
bony eminence, the promontory, which is formed by the bony capsule 
of the^r^ turn of the cochlea. Above and behind this eminence 
there is a depression, the pelvis of the oval window. At the bottom 
of the pelvis is an opening, the fenestra ovalis, which leads from 



ANTRUM 




Fig. 16 v — Inner Wall of Middle Ear Tract, from Eustachian Tube and Mastoid Antrum. 



the cavum into the vestibule of the labyrinth. The foot plate of 
the stapes articulates by an orbicular ligament with the edges of this 
window. Below the oval window and behind the promontory 
there is a depression leading inward, forward and upward, the 
pelvis of the round window. This opens through the round window, 
fenestra rotunda, into the base of the scala tympani of the first 
turn of the cochlea. The membrana tympani secondaria closes the 
round window. Up and down the face of the promontory there are 
tiny grooves and foramina for the tympanic plexus of nerves and 
vessels. Below and behind the promontory the inner Avail of the 
cavum becomes very rough with bony spicule and trabecular, 
which form small cells. The largest of these cells, which lies near 
the round window, is called the sinus tympanicus. Xear the 



THE MIDDLE EAR. 



407 



posterior lip of the oval pelvis there is a tiny pyramid perforated 
like a hollow needle or snake's fang. This is the processus perfora- 
tus for the passage of the tendon of the musculus stapedius. Above 
and in front of the oval pelvis there is a small curved bony lamella, 
the crista tubce or rostrum cochlea. Connected with the posterior 
end of a thin lamella of bone is the processus cochleariformis, or 
septum tubce. This lamella of bone extends forward, parallel to the 
tympano-pharyngeal tube, forming a closed canal for the musculus 



CREST EXTERNAL SEMI-CIR. CANAL 



EXTE RNAL SEMI-CIRCULAR CANAL 

PO STERIOR 5EMI-C.CANAL 

P03T.AND SUP.S.C. CAN. 




MASTOID TIP 



VAGINAL PROCESS 

STYLOID PROCESS 



Fig. 166. — Posterior Half of Vertical Section of Right Temporal Bone through the 
External and Internal Meati, showing Posterior Tympanic Wall (enlarged)'. 



tensor tympani. The tendon of the musculus tensor tympani turns 
outward at a right angle at the crista tubae to reach its attachment 
on the handle of the hammer. Along the upper edge of the oval 
pelvis there is an elongated rounded ridge, the Fallopian eminence. 
formed by the canal of the facial nerve or aqueduct of fallopius. 
The bony wall of the canal is sometimes partially deficient at this 
point. At the upper margin the inner wall of the cavum passes into 
the tegmen tympani. Posteriorly, the lower half of the inner wall 
passes into the posterior wall of the cavum, and the upper halt passes 



408 



DISEASES OF THE NOSE, THROAT AND EAR. 



into the inner wall of the aditus ad antrum. Anteriorly, the inner 
wall of the cavum forms the outer wall of the cochlea and passes into 
the anterior wall of the cavum below, and the inner wall of the 
tympano-pharyngeal tube above. The line of demarcation on the 
inner wall of the cavum between the atrium and epitympanum 
runs from the cristae tubae along the lower margin of the oval window 
to the lower lip of the aditus ad antrum. 

The superior wall of the cavum, called the tegmen tympani, is 
a thin lamella of bone which may be deficient in part. It separates 
the middle fossa of the skull from the cavum and supports the 
temporo-sphenoidal lobe of the cerebrum. Its upper surface shows 



LAMINA 5PIRAL15 COCHLEAE 



EX TERNAL SEN H-CIRCULAR CANAL 

VESTIBULE/ BEGINNING BA5AL TURN COCHLEA 

INTERNAL MEATUS 

COCHLEA 




CAROTID CANAL 



SULCUS TYMPANICUS 



Fig. 167. — Lower Half of Horizontal Section of Right Temporal Bone, cut through. 
External Auditory Meati showing the Lower Tympanic Wall. 



marks of the cerebral convolutions. In young specimens the line 
of the petro-squamosal suture runs parallel to the squamous portion 
of the temporal bone. On the under surface of the tegmen this 
suture is indicated by a ridge, the spina tegmenis mastoidei, which 
ends in the crista tegmenis in front, from which the suspensory 
ligament of the hammer hangs. The rest of this surface is slightly 
trabeculated. Posteriorly the tegmen tympani is continuous with 
the tegmen antri. Anteriorly, the tegmen tympani is continuous 
with the roof of the tympano-pharyngeal tube. Just before the 
tegmen tympani reaches the tube, it has a small transverse ridge, the 
spina transversa tympani, from which hangs a membranous curtain 
enclosing the anterior chamber of the epitympanum. Externally, 



THE MIDDLE EAR. 



409 



the tegmen tympani passes into the wall of the niche of the attic. 
Along the outer border the tegmen may have openings communicat- 
ing with cells, which extend over the osseous part of the external 
auditory meatus and up into the squama and into the zygomatic roots. 
The posterior wall of the cavum is somewhat trabeculated below. 
The cavum is separated from the jugular fossa by a plate of bone, 
which may be very thin and dehiscent. Above, the wall opens into 
the aditus ad antrum, forming its floor. On the lower anterior 
edge of this opening there is a small shelf or cella incudis for articula- 
tion with the short process of the anvil. 



CANALIS PROTENSORE TYMPANI 



PORUS ACUSTICUS 




NICHE IN EXTERNAL 
WALL. TYM PANUM 



UPPER WALL MEATUS 
ZYGOMATIC CELLS 
ROOT OF ZYGOMA 



EXTERNAL 
AUDITORY MEATUS 



PROMONTORY 



JUGULAR FOSSA 



05TIUM TYMPANICUM 
TUBAE 



STYLOID PROCESS 



LOWER WALL MEATUS 
SULCUS TYMPANICUS 
LOWER TYMPANIC WALL 



Fig. 168. — Anterior Half of Vertical Section of Right Temporal Bone, cut through 
the External and Internal Auditory Meati, Showing the Anterior Tympanic Wall 
(enlarged). 



The inferior wall of the cavum is more or less trabeculated. 
Posteriorly it is separated from the jugular fossa by a plate of bone 
which, in many specimens, is very thin and sometimes deficient. 
Anteriorly the inferior wall is separated from the knee of the carotid 
canal by a very thin plate of bone, which may also be deficient in 
part. 

The lower portion of the anterior wall is somewhat trabeculated. 
The bone covering the knee of the carotid canal may be very thin 



4-10 DISEASES OF THE NOSE, THROAT AND EAR. 

and perforated. This wall continues above to form the lower 
margin of the tympanic mouth of the tympano-pharyngeal tube. 

In pneumatic temporal bones, those with extensively developed 
systems of air cells, the trabeculated area of the cavum may commu- 
nicate with variously extensive series of pneumatic cells in the neigh- 
boring portion of the bone. 

The attic or epitympanic part of the cavum tympani forms an 
intermediate chamber between the atrium or drum proper (that 
portion of the cavum which is in immediate relation with the drum 
membrane) and the mastoid antrum. It is separated from the drum 
proper by the short process of the hammer, the articulation of the 
hammer and anvil, the tendon of the tensor tympani, the processus 
pro musculo tensore tympani, the long process of the anvil, the 
lower lip of the oval window, and the mucous membrane folds 
extending across this area. An almost horizontal plane of demarca- 
tion between the drum cavity proper and the attic is formed, but 
the division is oblique to the axis of the cavum. The passageway 
between the epitympanum and atrium is blocked by the ossicles, 
their tendons and ligaments, and also by mucous membrane folds. 
The passage varies in size and position, depending upon the amount 
of mucous membrane reduplication. There may be no more than 
a few pin-hole communications, or there may be wide spaces sur- 
rounding the major ossicles. The passage most frequently open 
lies between the short process of the anvil and the outer wall of 
the attic. The attic contains all of the ossicles except the handle 
of the hammer and opens posteriorly through the aditus ad antrum 
or passage into the antrum. The atrium opens anteriorly into the 
tympano-pharyngeal tube. 

The mastoid antrum is a chamber of variable size which leads 
backward and outward from the epitympanum, or upper part of 
the cavum, through the aditus ad antrum. Its length, measured 
from the tip of the short process of the incus, is on an average, u mm. 
iVt the posterior part of the floor of the aditus and adjacent antrum, 
there is a slightly rounded longitudinal elevation which is the bony 
capsule of the external or horizontal semicircular canal, and is 
called the eminentia canaliculi externi. The walls of the antrum are 
extensively trabeculated and covered with mucous membrane 
continuous with the lining of the epitympanum. The mucous 
membrane also forms trabecular, supplementing the osseous laby- 



THE MIDDLE EAR. 



411 



rinth, thus nearly filling up the antrum with cells. The axis of the 
antrum is continuous with the axis of the tympano-pharyngeal 
tube and extends outward and backward almost parallel to the 
posterior wall of the external auditory canal. The anterior wall 
of the antrum is the posterior superior wall of the canal. The 
trabecular of the antrum form air cells of a more or less complicated 
and extensive system. The roof of the antrum is called the tegmen 
antri; it is the backward continuation of the tegmen tympani, and 
has the same intracranial relations. The posterior wall of the 
antrum comes into relation with the sigmoid sinus and the posterior 



MIDDLE ROOT ,OF ZYGOMA 




SPINE OF MEATUS 



EXTERNAL 
AUD. MEATUS 



AUD. PROCESS 



VAGINAL PROCESS 



STYLOID PROCESb 



MASTOID CELLS 



TYMPANIC FISSURE 



Fig. 169. — Mastoid Right Process with Outer Table Removed, Showing Large Cells 
at base of Process and Diploe at Tip. 



cranial fossa. The internal wall of the antrum is formed by the 
part of the osseous labyrinth called the solid angle, which lies 
between the semicircular canals. In the cases where the sigmoid 
sinus approaches close to the posterior wall of the external auditory 
canal, the sinus passes externally to the antrum and the bony 
groove for the sinus forms the outer wall of the antrum. As a 
rule, however, the outer wall of the antrum, like the inferior wall, 
is made up of pneumatic cells of the mastoid process. 

The mastoid cell system is extremely variable in extent and in 
the arrangement of the cells. Although usually limited in extent 
to the mastoid process, in some instances the cells, besides occupying 
the whole mastoid process, extend inward to the apex of the petrous 



412 DISEASES OF THE NOSE, THROAT AND EAR. 

bone along its three surfaces; upward in the squama to the parietal 
bone; forward into the zygoma and to the sphenoid articulation; 
backward into the occipital bone; downward and inward toward 
the jugular fossa and through the occipital bone to the foramen 
magnum, and into the jugular process of the occipital bone, which 
forms the posterior wall of the jugular fossa and of the foramen 
lacerum posterium. At other times the cells are wanting. The 
cells may be small, medium, or large, or there may be a combination 
of cells of various sizes. The structure of the mastoid process is 
not always pneumatic or cellular; it may be made up in whole or 
in part of diploic bone, or of very hard eburnated bone. The cells 
are most persistent near the antrum. The outer walls or cortex 
of the mastoid portion of the temporal bone vary in thickness in 
different specimens, and even in different parts of the same speci- 
men, and are occasionally dehiscent in part. As a rule, the tegmen 
mastoideum is the thinnest mastoid wall. Sometimes cells approach 
very closely to the outer surface, to the inner surface or digastric 
aspect of the tip of the process, or to the internal surface along the 
groove for the sigmoid sinus. The walls may be deficient in any of 
these localities. 

The tympanic contents are the ossicular chain, muscles, tendons, 
ligaments, the reduplications of the mucous lining, and the facial 
and the chorda tympani nerves. The ossicular chain is made up 
of three minute bones: the hammer or malleus, anvil or incus, and 
the stirrup or stapes. These form a chain connecting the drum 
head with the oval window. The hammer is attached to the drum 
head; the stirrup is fastened in the oval window, and the anvil 
connects the other two bones and rests on the floor of the aditus ad 
antrum. The handle of the hammer is attached to the drum head 
by the outer surface of a cartilaginous sheath. A strong anterior 
ligament attaches the neck of the malleus and its processus gracilis to 
the crista tympani major of the annulus tympanicus. The processus 
gracilis , together with the fibers of the anterior ligament, extends 
some distance along the fissure of Glaser. The upper part of the 
head of the malleus is connected with the tegmen tympani by a small 
suspensory ligament running from the crista tegmeni, the anterior 
end of the spina tegmenis mastoidei. The hammer has a weak 
external ligament extending from its neck to the border of the notch 
or incisura Rivini. There is also an internal ligament of the malleus 



THE MIDDLE EAR. 



413 



in connection with the sheath of the tensor tympani tendons. 
Prussack's space is a small chamber lying externally to the neck of 
the malleus, bounded on the outer side by ShrapnelFs membrane, 
below by the short process of the hammer, above by the external 
ligament of the hammer, and anteriorly and posteriorly byPrussack's 
fibers. 



SUSPENSORY LIGAMENT OF 

MALLEUS 



NICHE OF ATTIC 



HEAD OF 
MALLEUS 

TENDON TENSOR 
TYMPANI 



UMBO 




FOLD MUCOUS 
MEMBRANE 

EXTERNAL 
LIGAMENT 
OF MALLEUS 



PRUSSACK'S 
SPACE 



SHRAPNELL'S 
MEMBRANE 

SHORT PROCESS 

MALLEUS 

MANUBRIUM MALLEI 
ANNULUS TENDINOSUS 



DRUM MEMBRANE 



FlG I70> — Longitudinal Section of Hammer, Cross-section of Attic, and Prussack's 
Space, Right Ear (enlarged). 



The position of Prussack's space is such that fluid in the part 
of the attic which is external to the ossicles, tends to drain into it. 
The posterior surface of the head of the hammer articulates with 
the head of the incus by a true joint with two facets to correspond to 
the two toothed processes of the anvil. The anvil is supported at the 
aditus ad antrum by the tip of its short process resting on a synchon- 
drosis and fastened by a double fan ligament. The lenticular 
process of the long process of the incus articulates with the head of 
the stapes by a true synovial joint. The stapes, a very small frail 
bone, articulates by the edge of its foot-plate with the orbicular 
ligament of the oval window. A synovial sac is found in this joint. 

The right or left ossicle is easily distinguished. Malleus.- In 



414 



DISEASES OF THE NOSE, THROAT AND EAR. 



order to distinguish the right from the left malleus, the short process 
should be held toward you with the handle pointing down. When 
the bone is in this position, the side of the head which has the facet 




ATTACHMENT 
^ OF ANTERIOR 
/' LIGAMENT 



LONG PROCESS 




- SHORT PROCESS 



ANTERIOR VIEW 



POSTERIOR VIEW 



Fig. 171 . — Malleus, (enlarged) . 



is the posterior surface, and the surface with the short process is 
the external surface. In this way the bone is demonstrated as belong- 
ing to the right or left side. If the facet is toward your left hand, it 
is a right bone; if toward your right hand, a left bone. 



UPPER 
ARTICULAR rACCT. 



LOWER 
ARTICULAR FACET 



_BODY 



SHORT PROCESS. 




_ LONG PROCESS 



LENTICULAR 
PROCESS 




LOWER 
ARTICULAR 
/ FACET 



FACET 
POST LIGAMENT 



LONG PROCESS — — - 



ANTERIOR VIEW 



EXTERNAL VIEW 



Fig. 172. — Incus (elarged). 



Incus. — To distinguish the right from the left, place the short 
process horizontally, the long process pointing down and the lower 
toothed facet facing you. As in the case of the malleus, the short 
process will point backward and determine the right or left bone. 



THE MIDDLE EAR. 



415 



If the short process is to your left, it is a right bone; if the short 
process is to your right, it is a left bone. 

Stapes. — To distinguish the right from the left, place the bone 
with its head up and resting on the convex edge of the foot plate; 
then the more curved or heavier crus will be the posterior one and 
indicate a right or left bone in the same way as the malleus or incus 



ARTICULAR FACET 


~X~~~~ 


-HEAD 






ANTERIOR CRUS J 

it 










1 


-HOLLOW 
OF CRUS 


ANTERIOR 
BORDER v 


UPPER BORDER 

^ — /_ POSTERIOR 

/ "N /BORDER 


J K- 

FOOT £"-— . 


=*> 




H 


^ , ^f 


PLATE 




/ ^~FOOT PLATE 










LOWER BORDER 



UPPER VIEW |NNER V(EW 

Fig. 173. — Stapes (enlarged). 

were located. If this crus is to your right, it is a left bone, and if 
to the left, it is a right bone. 

The tendon of the musculus tensor tympani, which is a compara- 
tively strong muscle, passes outward from the crista tubas on the 
inner wall of the cavum and is attached to the anterior border of 
the inner surface of the base of the handle of the hammer. The 

OUTER SIDE 




INNER SIDE 



Fig. 174. — The right epitympanum and antrum of a child two years old exposed by 
removal of tegmena antri and tympani, viewed from above. The epitympanum and 
atrium are connected only by a pin hole on the inner anterior side of the head of the 
hammer. The incus is buried in mucous folds (enlarged). 



tendon of the musculus stapedius passes forward from its tiny cana 
behind the oval pelvis and is attached to the posterior aspect of the 
head of the stapes. 

There is, besides the chain of bones, their ligaments and tendons. 
a system of folds and reduplications of the mucous membrane which. 
when fully developed, separates the atrium from the epitympanum or 



416 



DISEASES OF THE XOSE, THROAT AND EAR. 



attic. These folds exist in normal tympana, but are somewhat 
irregular in their arrangement. When fully developed, the folds 
envelop all the ossicles except the handle of the hammer. These 
folds extend backward into the antrum, supplementing the true 
pneumatic cells by air cells of mucous membrane. As a rule, the 
folds are either vertical or horizontal. The vertical folds are parallel 
to the three long axes of the two larger bones; that is, they are 
parallel to the axis of the hammer and the axis of both the long and 
short process of the anvil. Sometimes also the folds are paralle 
to the tensor tympani tendon. The horizontal folds are paralle 




EXTERNAL SIDE ^; 

Fig. 175. — Adult Tympanum. Tegmen removed, showing minimum of mucous 
membrane reduplications (enlarged). 



to the long axis of the anvil, and connect it with the inner, outer or 
upper walls of the tympanum. The mucous folds are especially 
abundant in the oval pelvis, extending in different directions from 
the stapes, as well as from the membrana propria of the stapes, 
which is a double sheet of mucous membrane enclosing an air space 
between the crura of the stapes. Most of the folds bind the crura 
of the stapes to the lower side of the oval pelvis. 

The handle and short process of the hammer may be distinctly 
seen when the drum membrane is normal. The reflected light from 
the end of the long process of the anvil, the shadow of the round 
pelvis, and the reflected light from the convexity of the promontory 
can be clearly seen through a thin transparent membrane. When 



EXTERNAL TOPOGRAPHY OF THE TEMPORAL BONE. 417 

the membrane is absent, inspection through the canal will, in most 
cases, disclose the inner wall of the cavum as far up as the oval 
window and the head of the hammer. 

The inner ear is the peripheral sound-perceiving apparatus and the 
peripheral space organ. It contains the sensitive nerve endings 
for sound and for the cosmic senses of space and equilibrium. 
The "inner ear is made up of a series of complicated canals in the 
hardest part of the petrous portion of the temporal bone, called the 
labyrinthine capsule. These canals are lined with a periosteal and 
serous membrane, or sero-periosteum, and are filled with lymph 
or serous fluid in which is suspended a membranous tube, called the 
membranous labyrinth. The bony tube comprises the vestibule or 
central chamber from which lead, posteriorly and superiorly, the 
three semicircular canals lying in the three planes of space and, 
anteriorly and inferiorly, the cochlea or snail shell. The membranous 
labyrinth is more complicated than the osseous labyrinth owing to 
certain constrictions and sacculations of its tube. The membranous 
labyrinth, surrounded by the osseous labyrinth, lies internally 
to the middle ear. Its position is readily located by the landmarks 
in the middle ear. The eminence of the external or horizontal 
semicircular canal, lying on the floor of the aditus ad antrum, is 
a landmark for the positions of the other two semicircular canals 
which lie at right angles to it; the posterior, behind and internal, 
and the superior, above and internal. The oval window indicates 
the vestibule into which it opens; the round window indicates the 
basal coil of the cochlea. From this point the coil of the cochlea 
runs forward and upward. 

The promontory forms the outer wall of the cochlea, and the 
tympanic end of the inner wall of the tympano-pharyngeal tube 
forms the apex of the cochlea. 

The internal auditory meatus is located at the base of the cochlea. 

GENERAL EXTERNAL TOPOGRAPHY OF THE 

TEMPORAL BONE AND STRUCTURES 

SURROUNDING THE EAR. 

Externally, the upper border of the zygoma gives a fixed line 
which can be used to locate anatomical relations by passing through 
it an imaginary horizontal plane. It indicates the level of the floor 
27 



41 8 DISEASES OF THE NOSE, THROAT AND EAR. 

of the middle cranial fossa and the summit of the tentorium cerebelli, 
which is attached to both lips of the groove for the lateral sinus 
from the knee of the sigmoid sinus backward. The posterior root 
of the zygoma forms the upper lip of the external osseous auditory 
canal and passes backward into the temporal ridge. The middle 
root forms the upper part of the anterior lip of the auditory canal. 
The anterior root forms the outer end of the articular eminence, 
which is the anterior boundary of the glenoid fossa. 

A curved line, convex superiorly, drawn from the apex of the angle 
between the squamous and mastoid portions of the temporal bone 
to the superior occipital protuberance, indicates the course of the 
lateral sinus. The direction of the temporal ridge where it joins the 
posterior root of the zygoma indicates the direction of the descend- 
ing limb of the sigmoid sinus. The apex of the angle between the 
squamous and mastoid portions of the temporal bone indicates the 
knee of the sigmoid sinus. Therefore, a line drawn through this 
point parallel to the lower end of the temporal ridge will indicate 
the location and direction of the descending limb of the sigmoid 
sinus. The level at which the sigmoid sinus turns inward to form 
its horizontal limb is indicated by the level of the bottom of the 
digastric groove, or the horizontal portion of the occipital bone. 
The distance between the knee of the sinus and the external osseous 
auditory canal is very variable; the sinus may impinge directly on 
the canal or lie some distance behind it. 

The general outer contour of the mastoid region gives a very 
slight indication of the position of the sinus. In large, well-developed 
mastoids, it is usually placed far back; in small pointed mastoids, 
with sharply convex bases, it may be placed far forward. The 
spine of the meatus indicates the lip of the posterior superior wall 
of the external osseous auditory canal. An indefinitely marked 
line descending forward over the face of the mastoid process indicates 
the position of the squamo -mastoidal suture. 

The inferior surface of the petrous pyramid presents the stylo- 
mastoid foramen and, just inside this orifice, is the entrance to the 
posterior canal of the chorda tympani nerve. This foramen serves 
for the exit of the facial nerve from the lower end of the aqueduct 
of Fallopius or facial canal. It is situated just behind the base of 
the styloid process, and at the anterior end of the digastric groove. 
Both the styloid process and the digastric groove are exceedingly 



EXTERNAL TOPOGRAPHY OF THE TEMPORAL BONE. 



419 



useful landmarks to indicate the position of the descending arm of 
the facial nerve. The digastric groove lies on the inner side of 
the base of the mastoid process and runs parallel to this surface 
of the process. It is filled by the posterior belly of the digastric 
muscle. A small secondary mastoid process is not infrequently 
seen lying internal to the digastric groove. It is usually pneumatic. 
For convenience in description, the facial canal is divided into 
three parts: The internal limb, the tympanic limb, and the mastoid 
or descending limb. The course of the internal limb of the facia 



GROOVE INFERIOR PETROSAL SINUS 



EXIT CAROTID CANAL 
EUSTACHIAN TUBE 
ARTICULAR 
EMINENCE 



OPENING CAROTID CANAL 

JACOBSEN'S NERVE FORAMEN 
ARNOLD'S NERVE FORAMEN 
JUGULAR FOSSA 
JUGULAR FACET 




VAGINAL PROCESS 
GLENOID FOS'SA 



Fig. 176. — Under surface of Right Temporal Bone. 



canal is directed outward from the upper internal quadrant of the 
internal auditory meatus to the hiatus of Fallopius. The hiatus 
of Fallopius is close to the inner wall of the cavum tympani, directly 
posterior to the crista tubae and in front of the oval pelvis. At this 
point the facial canal turns backward at a right angle to form the 
tympanic limb of the aqueduct. The wall of the canal serves as 
the upper lip of the oval pelvis, and is known as the Fallopian 
eminence. The Fallopian canal, gradually curving downward to 
form the mastoid limb, passes below, in front and external, to the 
external semicircular canal, and, forming the lower lip of the adit us 
ad antrum, passes behind the posterior wall of the cavum. From 
there the course of the mastoid limb is almost vertically downward 
to the stylomastoid foramen; that is, the mastoid limb is inclined 
about 45 outward from the plane of the annulus tympanicus or 



420 



DISEASES OF THE XOSE, THROAT AND EAR. 



drum membrane. The mastoid limb of the canal of the facial nerve 
may pass 5 mm. or less posterior to the posterior limb of the annulus 
tympanicus, or the posterior wall of the external osseous auditory 
canal. Anomalous positions of the canal for the nerve are extremely 
rare, and are indicated by abnormality in the position of the digastric 
fossa and stylomastoid foramen. 

The jugular fossa, which contains the jugular bulb, opens down- 
ward, offering an opportunity to curette it from below. ' It is 
situated at the inner side of the styloid process. 



PETRO-SQUAMOSAL SUTURE 



SQUAMA 

GROOVE MIDDLE 
MENINGEAL 
INTERNAL 
MEATUS 



ZYGOMA 



EMINENCE SUPERIOR 

SEMI-CIRCULAR CANAL 



GROOVE SUPERIOR 

PETR05AL SINUS 



PROMINENCE POSTERIOR 
/ SEMI-CIRCULAR CANAL 




GROOVE 

INFERIOR PETROSAL SINUS^ 



CAROTID CANAL" 
VAGINAL PROCESS 



STYLOID PROCESS 



MASTOID PROCESS 



JUGULAR FOSSA 
AQUEDUCTUS COCHLEAE 



Fig. 177. — Inner Surface of Right Temporal Bone. 



The outer posterior surface of the mastoid portion has one or 
more mastoid foramina for the passage of the mastoid emissary veins. 
They are of varying size, and enter the bone along the mastoido- 
occipital suture. They usually unite before opening into the groove 
for the sigmoid sinus. 

The superior or anterior surface of the petrous bone shows an 
elevation for the superior semicircular canal, and at the apex, a 
depression for the Gasserian ganglion. At the center of the anterior 
half of the surface there is a small opening — the hiatus of Fallopius 



EXTERNAL TOPOGRAPHY OF THE TEMPORAL BONE, 



421 



— leading to the facial canal. The posterior border of this surface 
or superior angle of the pyramid is grooved for the superior petrosal 
sinus which connects the cavernous sinus at the tip of the pyramid 
with the knee of the sigmoid sinus. This border also gives attach- 
ment for the tentorium cerebelli. 

The posterior surface of the petrous pyramid rests against the 
lateral lobe of the cerebellum. The sigmoid sinus grooves the 
external inferior border of this surface. At the junction of the 
inner and middle thirds of this surface of the petrous bone is 
located the internal auditory meatus, through which the facial, 
the intermediary, and the cochlear and vestibular branches of the 
auditory nerves pass. Below the meatus lies the posterior opening 
of the jugular bulb, which opens horizontally forward from the inner 
end of the horizontal limb of the sigmoid sinus at right angles to 
this portion of the sinus and also at right angles to the axis of the 



SUPERIOR FOSSA 

I 



SUPERIOR CRIBRIFORM AREA -— 



MIDDLE CRIBRIFORM AREA 
FORAMEN SINGULARE 




ENTRANCE TO THE FACIAL CANAL 



TRANSVERSE CREST 



ORIFICE OF THE CANAL 
OF THE MODIOLUS 



SPIRAL CRIBRIFORM TRACT 



INFERIOR FOSSA 



Fig. 178. — The Foramina in the Fundus of the Left Internal Auditory Meatus of a 
Child at Birth (f). Diagrammatic. (Morris.) 



jugular bulb and vein. (These right angles make it impossible, 
in most cases, to curette the jugular bulb through the sigmoid sinus, 
or the sigmoid sinus through the jugular veins or bulb.) Along 
the inner third of the lower border of the posterior surface of the 
pyramid there is a shallow groove for the inferior petrosal sinus, 
which runs from the cavernous sinus in front outward, backward. 
and downward to the inner wall of the dome of the jugular bulb. 
Under the internal auditory meatus in the posterior inferior border 
of the petrous pyramid, there is a pyramidal depression for the 
entrance of the aqueduct of the cochlea. (External to this opening 
on the posterior pyramidal surface between the internal auditory 
meatus and sigmoid groove is the opening of the aqueduct of the 
vestibule.) Between the aqueduct and the groove for the sigmoid 



422 DISEASES OF THE NOSE, THROAT AND EAR. 

sinus a slight elevation indicates the location of the posterior semi- 
circular canal. The third, fourth, fifth, sixth, seventh, eighth, ninth, 
tenth, and eleventh cranial nerves are in close relation to the posterior 
surface of the apex of the petrous pyramid. 

The deep cervical fascia is attached to the base of the skull, 
lying beneath the platysma and surrounding the muscles and vessels 
of the neck. While it favors the passage of enclosed fluid downward 
to the thorax, it prevents passage of fluids backward among the 
vertebral muscles which are protected by the prevertebral fascia. 
The fasciae of the region under consideration are important since 
they determine the course which pus may take after perforation of 
the cortex of the mastoid region. Perforation of the base or outer 
surface of the mastoid process leads to a subperiosteal abscess in the 
immediate neighborhood of the perforation. Perforation of the 
inner surface of the mastoid process or of the digastric fossa leads 
to a deep abscess in the neck with pus burrowing indefinitely down- 
ward to the mediastinum and pleural cavity. Perforation through 
the outer surface of the tip of the process allows the burrowing of 
pus within the sheath of the sternocleidomastoid muscle and 
cellulitis within the deep fascia of the neck. 

BLOOD SUPPLY. 

The ear has its chief blood supply from the external carotid 
artery through the posterior auricular, occipital, and temporal 
branches. Most of the auricle is supplied by the posterior auricular 
and occipital through perforating branches that come from the 
posterior auricular fossa. The helix, tragus, and lobe are supplied 
by the auriculo-temporal arteries from the superficial temporal in 
front of the ear, which anastomose with the posterior auricular. 

External Auditory Canal. — The anterior wall of the cartilaginous 
canal is supplied by the anterior auricular artery, which passes 
between the bony canal and the cartilage. The posterior wall of the 
cartilaginous canal is supplied by the posterior auricular artery. 
The bony meatus derives its blood supply from the deep auricular 
branch of the internal maxillary artery. 

The Drum Membrane. — The cutaneous layer of the drum 
membrane is supplied by the anterior manubrii mallei from the 
deep auricular; the mallear artery passes through the annulus 



BLOOD SUPPLY. 423 

tendinosus, follows along behind the manubrium and forms 
radial anastomoses. The mucous layer is supplied by the anterior 
temporal from the internal maxillary through the fissure of Glaser 
and anastomoses with the cutaneous supply. 

Eustachian Tube. — The roof of the tube is supplied by a branch 
of the middle meningeal from the internal maxillary artery, called 
the superficial petrosal branch. The floor of the tube is supplied 
by the basilar branch of the ascending pharyngeal artery from the 
external carotid; also by the Vidian artery through the petrosqua- 
mosal fissure from the superior palatine, a branch of the middle 
meningeal. The descending palatine joins the ascending palatine 
branch of the facial artery and joins also the ascending pharyngeal 
branch of the external carotid. 

The mastoid process and cells are supplied by mastoid branches of 
the stylomastoid artery. A branch of the facial artery anastomoses 
with the stylomastoid artery, from the Fallopian canal. 

The antrum and attic are supplied by branches of the middle 
meningeal artery through the petrosquamosal suture. 

The tympanic cavity is supplied anteriorly by the tympanic 
branch of the external carotid through carotido-tympanic canal- 
iculi. The anterior ligament of the malleus is supplied by the 
anterior tympanic artery of the internal maxillary through the 
fissure of Glaser, and joins the stylomastoid artery in the drum 
head. The temporal artery may send a small branch through the 
fissure of Glaser. The tympanic branch of the internal maxillary 
artery anastomoses also with the tympanic branch of the internal 
carotid, the Vidian branches of the internal maxillary, the descend- 
ing palatine, and the pharyngo-palatine, and sends small branches 
to the tympano-pharyngeal tube and its muscles. The posterior 
portion of the tympanic cavity is supplied by the posterior tympanic 
artery of the stylomastoid through the canal of the chorda tympani. 
The stapedius muscle is supplied by the stapedic artery and by 
branches of the stylomastoid artery in the Fallopian canal. The 
stylomastoid artery enters the foramen of the same name, together 
with the tympanic branch of the internal maxillary, and in the 
cavum joins branches of the superficial petrosal a branch oi the 
middle meningeal. The stapes receives its blood supply by the 
anastomosis of the stylomastoid with the superior petrosal artery. 
which enters through the petrosquamosal suture from the middle 



424 DISEASES OF THE NOSE, THROAT AND EAR. 

meningeal, and anastomoses with the labyrinthine vessels. The 
superior petrosal supplies the hammer, anvil, and internal tympanic 
wall. The tensor tympani muscle is supplied by a branch of the 
middle meningeal through the hiatus of Fallopius. 

The blood supply of the upper portion of the tympanic cavity 
is received from the superior tympanic branches of the middle 
meningeal and the superficial petrosal branch from the roof of the 
tympano-pharyngeal tube. The lower portion of the tympanic 
cavity is supplied by the inferior tympanic artery, a branch of the 
ascending pharyngeal through the canaliculi tympanici. The 
walls of the promontory and endosteum of the labyrinth are supplied 
by communicating branches of the internal auditory artery which 
pass through vascular perforations of the promontorial wall. 

Labyrinth. — The osseous semicircular canals are supplied by the 
arteria subarcuata through the fossa subarcuata, the internal audi- 
tory artery, a branch of the basilar through the internal auditory 
meatus. The membranous semicircular canals — utricle and saccule 
— are supplied by the vestibular artery, a branch of the internal 
auditory, which also supplies the vestibular nerve. The blood supply 
of the cochlear nerve, spiral ganglia, osseous spiral lamella, scala 
vestibuli, periosteum of walls of scalae and spiral ligament is 
derived from the cochlear artery, a branch of the internal auditory. 
The internal auditory artery follows the auditory nerve and ends 
in loops of the terminal vessels. Some blood supply also reaches 
the membranous labyrinth from the inner walls of the osseous 
labyrinth. The chief of these branches is given off from the stylo- 
mastoid artery as it passes through the stylomastoid canal. These 
branches supply the semicircular canals and cochlea. The internal 
carotid traverses the inner half of the petrous pyramid and comes 
into close relation with the cavum tympani and with the tympano- 
pharyngeal tube. The middle meningeal artery passes through 
the foramen spinosum at the outer side of the osseous Eustachian 
tube, and supplies the upper surface of the petrous pyramid and the 
inner surface of the squama. 

VEINS. 

The veins of the auricle empty into the superficial temporal and 
external jugular veins. The veins of the antrum and attic empty 



VEINS. 425 

into the posterior auricular vein and into the sigmoid sinus. The 
veins of the promontory and endostium of the labyrinth empty 
into the middle meningeal veins and deep auricular veins. 

The veins of the labyrinth empty chiefly through the internal 
auditory veins accompanying the internal auditory artery, which 
empties into the inferior petrosal sinus. There are other direct 
connections with the neighboring venous sinuses, namely, the inferior 
and superior petrosal, the sigmoid, and the petrosquamosal sinuses. 
Blood from the vestibule and semicircular canals returns in part 
through the vena aquseductorum vestibuli which empties into the 
inferior petrosal sinus. The blood from the cochlea is returned 
partly through the vena aqueducti cochlea into the bulb of the in- 
ternal jugular vein. The labyrinthine veins communicate with the 
tympanic veins through the tympanic wall. 

The venous system of the extracranial part of this region is very 
similar in its arrangement to that of the arterial system. The 
veins from the posterior part of the auditory canal and auricle empty 
into the mastoid and external jugular veins. These veins, draining 
the anterior part of the canal and auricle, empty into the temporal 
veins. The deeper veins may empty into the pterygoid plexus, and 
there may be more complicated anastomoses with the lingual, 
superior hyoid, and facial veins. The veins of the anterior wall of 
the Eustachian tube drain into a vein communicating with the 
cavernous sinus. There is an erectile venous plexus at the pharyn- 
geal mouth of the tube which is continuous with the erectile system 
of the turbinals. Some of the veins from the tympano-pharyngeal 
tube flow into the internal jugular, and the anastomosis of the deep 
and superficial veins is complete. In the cavum, the communication 
of the arterioles and veins is direct, and the capillary system is very 
much reduced. Facts of importance are the free communication 
of the superficial and median veins with the intracranial venous 
system through the, mastoid veins, which communicate with the 
sigmoid sinus; the communication of the upper pharyngeal veins 
and the veins of the upper part of the face, and the communication 
of the veins about the pterygoid plexus with the cavernous sinus. 

The intracranial venous system of the region of the ear and its 
communications with the tympanic veins have attracted special 
surgical attention of late because of the direct conveyance oi infection 
along the veins. The relations of the venous system oi the middle 



426 



DISEASES OF THE NOSE, THROAT AND EAR. 



ear and the sigmoid sinus are very important throughout the whole 
extent, but chiefly so at two points. First, at the knee of the sigmoid 
sinus, where this sinus, a continuation of the lateral sinus, bends 
downward, forward, and inward; and, second, where the sigmoid 




HALMIC VEIN 
FRONTAL 



SUPRA- 
ORBITAL 
VEIN 



SUPERIOR 
OPHTHALMIC 
. VEIN 
-I NASAL 
VEINS 
ANGULAR 
VEIN 

OPHTHALMIC 
COMMUNICATING 
VEIN 



INFRA 
ORBITAL 
VEIN 

NASALVEINS 

SPHENO- 
MAXILLARY 
VEIN 

FACIAL 

COMMUNICATING 
VEIN 



^INTERNAL MAXILLARY 
VEIN 



.RIGHT AURICLE 

Fig. 179. — Diagram of Veins and Sinuses of Head and Neck, Left Side. 



sinus empties into the posterior portion of an inverted cup, the 
jugular fossa, which contains the jugular bulb, the source of the 
internal jugular vein. 

The knee of the sigmoid sinus is important because of its relation 
to the antrum mastoideum, in front of which it lies. The jugular 



VEINS. 



427 



bulb is important not only because of the fact that it is the meeting 
place of the sigmoid and inferior petrosal sinuses, but also because 
of its relation to the floor and posterior wall of the cavum tympani 
with which it is often in immediate contact, the bony wall in some 
cases being partially wanting. 

Next in importance are the veins and venous sinuses in immediate 
connection with the sigmoid sinus. These are the inferior petrosal 



CIRCULAR SINUS 



HYPOPHYSIS 



CAVERNOUS -, 
SINUS 



BASILAR s\l 
SINUS 




OPTIC NERVE 



INTERNAL CAROTID 
■"" ARTERY 
— SPHENOFRONTAL 
SINUS 

-SELLATURCICA 



TRANSVERSE 
SINUS 



INFERIOR 

PETROSAL 

SINUS 



SUPERIOR 

"PETROSAL 

SINUS 



.SIGMOID 
SINUS 



-LATERAL SINUS 



OCCIPITAL SINUS ' 



LONGITUDINAL SINUS 



Fig. 180. — Base of Skull, Showing Venous Sinuses Diagrammatic. 



sinus, the superior petrosal sinus, the petrosquamosal sinus, the 
mastoid veins, and the meningeal veins. These smaller sinuses and 
veins, like the veins in the extremities, have a tendency to occur in 
pairs. The superior and inferior petrosal sinuses empty into the 
cavernous sinus which has direct communication with the sinus of 
the opposite side through the transverse and the circular sinuses. 
The cavernous sinus also communicates with the pterygoid plexus 
of veins and through this with the external jugular. Through 



428 



DISEASES OF THE XOSE, THROAT AND EAR. 



the veins of the upper part of the face the cavernous sinus communi- 
cates with the facial veins, 

There is constant variation in the relative sizes of the several 
intracranial sinuses and veins. This variation in size causes a 
consequent variation in their exits from the cranium. These 
veins of exit are the internal jugular, the mastoid emissaries, the 
vertebral, and those which empty forward from the middle or anterior 

PLATYSMA 

THYROID CARTILAGE 
LARYNGEAL CAVITY 

ANTERIOR JUGULAR VEINS 
STERNOTHYROID MUSCLE 
PHARYNGEAL CAVITY 
SUPERIOR THYROID ARTERY 
SUPERIOR CORNU OF 
THYROID CARTILAGE 
INFERIOR CONSTRICTOR OF 

PHARYNX 

STERNOCLEIDOMASTOID M. 

COMMON CAROTID ARTERY 

SYMPATHETIC NERVE 

INTERNAL JUGULAR VEIN 

PNEUMOGASTRIC NERVE 

EXTERNAL JUGULAR VEIN 

M. 



LONGUS COLLI 
-LONGUS CAPITIS M. 
SCALENI M.M 
VERTEBRAL A. AND V. 
BODY OF VERTEBRA 




SPINAL CORD 



VERTEBRAL ARCH 



SPINOUS PROCESS 



Fig. 181. — Section of Xeck, Showing Topographical Position of Internal Jugular Vein. 



fossa. The largest of these venous exits is the jugular foramen, 
or foramen lacerum posterium, which is the passage for the sigmoid 
sinus into the jugular bulb. Occasionally one or the other of the 
jugular foramina will be reduced to very small proportions. The 
same is true of any of the other exits. 

The superior petrosal sinus connects the knee of the sigmoid sinus 
with the cavernous sinus. It runs along the superior angle of the 



LYMPHATICS. 429 

petrous pyramid and lies at the attachment of the tentorium cerebelli. 
Close to the orifice and at the knee of the superior petrosal sinus are 
other orifices for smaller cerebral veins. 

The inferior petrosal sinus runs from the inner surface of the 
dome of the jugular bulb through the jugular foramen to the 
posterior end of the cavernous sinus. 

The internal jugular vein rises at the jugular bulb and runs a 
straight course down the neck to empty into the right or left innomi- 
nate vein. Throughout its course its sheath lies against the posterior 
inner border of the sheath of the sternocleidomastoid muscle. It 
lies external and anterior to the internal and common carotids, and 
external and anterior to the pneumogastric nerve. In its course 
downward, the jugular has a number of branches, the most important 
of which is the facial vein which joins the internal jugular a little 
below the middle course of the jugular. The facial veins receive 
blood which flows anteriorly from the superior and inferior petrosal 
sinuses through the cavernous sinus. It is, therefore, an important 
means of collateral return flow of blood from the brain in case of 
closure of the upper end of the internal jugular. There are extensive 
superficial venous anastomoses of the right and left side. The 
anastomoses of the large intracranial and superficial veins are also 
very extensive. The intracranial anastomoses are extensive and 
bilateral. 

LYMPHATICS. 

The lymphatics of the ear are abundant and communicate with 
the superficial and deep nodes of the neck and with the lymphatics 
of the nasopharynx and mediastinum. There are one or more 
lymph nodes situated on the outer surface of the mastoid process. 

The lymph glands which drain the cavum conchae and external 
auditory canal are to be found in front of the tragus. The lymph- 
atic drainage also goes into the lower anterior lymphatic vessels. 
The triangular fossa and the anterior surface of the helix drain 
into the highest mastoid gland and the upper anterior lymphatic 
vessels. 

The helix, antihelix, and the posterior surface of the pinna drain 
into the mastoid and cervical glands and into the posterior lymphatic 
vessels. The lobe and auditory canal drain into the parotid lymph 



430 DISEASES OF THE NOSE. THROAT AND EAR. 

glands and posterior lymphatic vessels. The drumhead and tym- 
panic cavity drain into the mastoid glands. The lymph from the 
labyrinth drains through the aqueduct into the subarachnoid space. 
The lymphatics of the labyrinth communicate both with those of 
the cranial cavitv and with those of the middle ear. 



IXXER EAR OR LABYRIXTH AXD XERVES OF THE EAR. 

The peripheral sense organs of the labyrinth are three in number, 
the cochlea, the semicircular canals, and the vestibule. These sense 
organs give rise to sensations of hearing, and change of manu- 
metric pressure to the sensation of rotatory, angular, and progress- 
ive movements in space, and to the sensation of the direction of 
gravitation. The sense perception of the vestibule and semi- 
circular canals includes with the sense of gravity, the sense of 
the direction of motion, the sense of change in the rate of motion, 
as well as of rotation and of progression; to this may be still further 
added the sense of geotropic motion of falling. Collectively these 
senses are combined in the peripheral organ of equilibration. The 
sense of change of manumetric pressure is derived from sensations 
of the drum membrane, and from the pressure of the foot-plate of 
the stapes. 

The osseous labyrinth is lined with a thin membrane with the 
periosteum on one side and serous membrane covered with cuboid 
endothelium on the other. The membrane is continuous with the 
dura mater through the cribriform plate and the aqueducts. This 
membrane-lined tube is filled with perilymphatic fluid in which 
another membranous tube is partially suspended. At various 
points, however, the second tube is also closely attached to the bony 
walls. The portion of the inner tube or membranous labyrinth 
located in the cochlea contains the terminal nerve endings of the 
cochlear branch of the auditory nerve. These nerve endings are 
especially differentiated for the perception of molecular motion or 
sound vibrations. The nerve endings of the vestibular branch of 
the auditory nerve, which are specialized for the perception of molec- 
ular motion interpreted as position and motion in space, are found 
in the membranous vestibule and in the membranous semicircular 
canals. 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR, 



43 1 



The osseous labyrinth has five macroscopic openings in addition 
to very many small openings for blood-vessels: i. the oval window 
or fenestra ovalis, opening into the vestibule; 2. the round win- 
dow or fenestra rotunda, opening into the scala tympani of the 
cochlea; 3. the aquaeductus cochlae, opening into the scala vestibuli 
of the cochlea; 4. the aqueductus vestibuli, opening into the vestibuli, 
and 5. the cribriform openings through the fenestrated plate of the 
internal auditory meatus. 

The osseous vestibule is the common central cavity, its inner wall 
lying against the peripheral end of the internal meatus, and its 




Fig. 182. — Fig. A, Left Labyrinth, Outer Side. B, Right Labyrinth, 
Inner Side. C, Left Labyrinth from above. 

a, Foramina for cochlear nerve; b, Fenestro rotunda; c, Fenestro ovahs; d, pos- 
terior ampulla of semicircular canal; e. Superior ampulla of semicircular canal; /, 
External ampulla of semicircular canal; g, Common limb of superior and posterior 
semicircular canals; h, External canal; i, Posterior canal; k, Anterior canal; m. Vestibule; 
n, Cochlea; 0, Base of cochlea; p, Cupola of cochlea; g, Recessus hemiellipticus of 
macula acustica utriculi; r, Recessus hemisphericus of macula acustica, and s. Aquae- 
ductus vestibuli; t, Aquseductus cochleae. 



outer wall surrounding the fenestra ovalis. It lies behind the 
cochlea and in front of the semicircular canals. Posteriorly and 
superiorly the osseous vestibule shows the orifices of the semi- 
circular canals, five in all, one of the openings being common to 
two canals. Anteriorly and inferiorly, there is an aperture into the 
scala vestibuli of the cochlea. Near the orifice of the posterior and 
superior semicircular canals there is a tiny foramen leading into the 
aqueduct of the vestibule. 

The semicircular canals, three in number, are situated above 
and behind the vestibule. The canals are nearly at right angles 
to each other, representing the three dimensions of space. One 
extremity of each canal is larger than the other extremity, and is 



432 DISEASES OF THE NOSE, THROAT AXD EAR. 

called the ampulla. The anterior or superior canal of one side, and 
the posterior of the other, lie in parallel planes. Both external 
canals are in the same plane. The anterior or superior canal lies 
in a vertical plane at right angles to the posterior surface of the 
petrous pyramid. The posterior is also vertical, but lies parallel to 
the posterior surface of the pyramid and is, therefore, at right angles 
to the superior as well as to the external or horizontal canal, which 
lies in a horizontal plane. 

The cochlea, as its name implies, is a conchoidal spiral tube, the 
cochlear canal, which is wound into a cone, making two and a half 
turns about an axis, the modiolus, the latter having a nearly horizontal 
axis directed outward. The base of the cone rests on the bottom 
of the internal meatus and is perforated for the filaments of the 
cochlear nerve. The modiolus is also perforated for the cochlear 
nerve filaments. The coils of the cochlear canal are known as the 
apex, central and basilar. The lamina spiralis is a spiral shelf 
attached to the inner Avail of the spiral cochlear canal, partially 
dividing it into an upper tube, called scala vestibuli, and a lower tube 
called scala tympani. This scala tympani does not open directly 
into the vestibule, but communicates with the typanum through 
the fenestra rotunda or round window. It opens into the vestibule 
only over the lamina spiralis. The lamina spiralis is perforated 
for the passage of the fibers of the cochlear nerve to the papilla 
acustica, or organ of Corti, and contains at its base a spiral en- 
largement of these canals, called the spiral canal, for the spiral- 
ganglion of the cochlear nerve. Close to the fenestra rotunda 
and on the inner wall of the scala tympani there is a tiny foramen, 
the aqueduct of the cochlea. 

The serous membrane lining the osseous labyrinth also covers 
the membranous labyrinth wherever it is not attached to a bony 
wall. There is a large perilymphatic cistern adjacent to the oval 
window, 3 mm. in depth and 3 mm. from before backward. A tube 
of the lining membrane passes from the vestibule into each semi- 
circular canal and into the scala vestibuli of the cochlea, lining the 
scala vestibuli to the cupola or apex; then continuing through the 
helicotrema or passage-way at the apex of the cochlea, into the scala 
tympani, which it also lines, it finally forms a blind pouch at the 
lower end of the scala tympani. The membrana tympani secandaria 
of the round window closes the lower end of the scala tympani. 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR. 



433 



Slightly above the round window on the inner wall of the scala 
tympani, the perilymphatic membrane leads into a narrow mem- 
branous tube, the ductus perilymphaticus, which lines the osseous 
aqueduct of the cochlea and empties into the subarachnoid space 
at the lower posterior border of the petrous bone, close to the jugular 
bulb. Thus, the subarachnoid space and the perilymphatic space 
communicate. The perilymphatic space communicates with the 
subdural space through the porus acusticus or cribriform plate of 
the internal meatus. 

INNER BORDER 
A 



VESTIBULAR 
BORDER 




OUTER BORDPR 



Fig. 183. — Left Membrana Tympani Secundaria. 1, Outer Surface; 2, View from 
Cochlear Border; 3, View from Outer Border, Diagramatic 

The membrana tympani secondaria looks backward, downward, 
and outward, and is attached in the frame of the fenestra rotunda 
at the inner end of the round pelvis. The area of the membrane is 
about twice the area of the tympanic orifice of the round pelvis. 
It is somewhat cordate, with nearly equal diameters, a rounded con- 
vex outer or anterior border, and a concave inner or posterior 
border. The membrane does not lie flat, but is folded along its 
inner border to fit the undulations of the inner border of the round 
window. The chief fold of the membrane is concave outward, the 
minor fold convex. The membrane is composed of a connective 
tissue portion, or membrana propria, with fibers radiating from the 
apex of the curve of the membrane. Externally, it is covered by 
thin mucous membrane; internally, by an endothelial lining. 
bathed in the perilymph of the perilymphatic tube of the scala 
tympani. The membrana tympani secondaria closes the extremity 
of the scala tympani in the basal whorl of the cochlea. It is nearly 
at right angles to the axis of the scala tympani. 
28 



434 



DISEASES OE THE XOSE. THROAT AXD EAR. 



The endolymphatic sac or true membranous labyrinth is a tube with 
its walls parallel to the osseous walls, except in the vestibule. The 
membranous labyrinth is lined with epithelium, and is completely 
surrounded by the perilymphatic sac. except where attached to the 
osseous wall. The membranous labyrinthine tube has three chief 
parts connected only by very narrow conduits. Two of these parts are 
placed in the vestibule; the third, in the cochlea. The latter, which 




Fig. iSj. — Diagram of Membranous Labyrinth. (Deaver.) 
i. Saccule; 2, Ampullae; 3, Ampullae, 4, Superior semicircular canal; 5, Posterior 
semicircular canal; 6, Scala media of cochlea: 7, Canalis reuniens; 8, Utricle: 
9, Ductus endolymphaticus : 10, Ampulla; 11, External semicircular canal. 



is called the scala media, is the anterior one. It lies against the outer 
osseous wall of the cochlear canal, between this wall and the lamina 
spiralis, and between the scala vestibuli and tympani. The posterior 
of the two parts of the membranous labyrinth in the vestibule — the 
utricle — sends branches through the semicircular canals; the third 
part of the membranous labyrinth., the saccule, which is a small 
rounded bag, communicates with the utricle through the forked 
end of the ductus endolymphaticus, and with the scala media of the 
cochlea bv a small tube, called the canalis reuniens. 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR. 435 

The endolymphatic, sac has a drainage-tube like the perilymphatic 
sac. In this case, the ductus endolymphatkus passes through the 
osseous aquceductus vestibuli. The duct opens from the saccule and 
utricle and empties into a small lymph system, the saccus endolymph- 
aticus or recessus Cotugni in the dura mater on the posterior surface 
of the petrous bone. The duct drains both the utricle and the 
saccule by means of its forked extremity, and communicates with 



wmjiT 




Fig. 185. — Diagram of Right Labyrinth, Viewed from Outer Side. 
The Perilymphatic Tube is Closed. The Endolymphatic 
Tube is Cross-lined. The Neuro-epithelial areas 
are black. 
a, Anterior semicircular canal; b, Posterior semicircular canal; c, External semi- 
circular canal; d, Cochlea; e, Vestibule; /, Sacculus and Macula acustica sacculi; 
h, Utriculus and macula acustica utriculi; i. Ductus endolymphaticus; /, Ampulla of 
superior semicircular canal and crista acustica; m, Ampulla of external semicircular 
canal and crista acustica; n, Ampulla of posterior semicircular canal and crista acustica; 
o, Round window; p, Oval window; s, Scala media and papilla acustica; /, Ductus peri- 
lymphaticus. 



the subdural and subarachnoid spaces. The utricular arm of the 
ductus endolymphaticus opens from the utricle near the common 
orifice of the superior and posterior semicircular canals. The 
saccular arm of the duct opens low down on the outer wall of the 
saccule. The saccule and the utricle each have a saucer-shaped 
macula acustica, made up of neuro-cpithelium consisting of hair 
cells and filiform cells. The neuro-epithelium is connected with 
the vestibular nerve and is covered with otoliths suspended among 



43 6 



DISEASES OF THE NOSE, THROAT AND EAR. 




Fig. 186. — Microscopic Section of Neuro-epithelial Structure of Macula 
Acustica Saculi. 
a, Otoliths suspended in mucus; b, Hairs of the neuro-epithelial cells, mucous 
cells and shreds of mucus; c, Neuro-epithelial cells and supporting cells; d. Basement 
membrane. 




MUCOUS CELL 



NERVE FIBERS 



FILIFORM CELLS 



Fig. 187. — Transverse Microscopic Section of Crista Acustica Utriculi. Shows the 
hairs of the epithelium agglutinated in bundles. 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR. 



437 



the hairs in mucous jelly. These otoliths are crystals of carbonate 
of lime, about 5 micromillimeters long. The macula acustica 
of the saccule has its curved concave surface directed backward, 
outward, downward, and upward; in the utricle it is directed inward, 
backward, and downward. The endolymphatic or membranous 
semicircular canals are much smaller than the perilymphatic or 
osseous canals. The membranous canals are attached to the concave 
outer side of the osseous canals. Each membranous canal has an 
ampulla or enlargement of one end, corresponding to the ampulla of 
the osseous canal. Situated on the convex side of each ampulla 
is a crista acustica corresponding to the maculae acusticae and 
composed of neuro-epithelium furnished with sensitive hairs. 



CUPOLA 



MODIOLUS 
HELICOTREMA 



LAMINA SPIRALIS OSSEA 



THIRD TURN 



SECOND 
TURN 




:88. — Cross section of macerated cochlea (enlarged). 

In describing the cochlea, it is treated as a distinct conical object, 
with base and apex, without any reference to the planes of the body. 
The r/iembrana basilaris supports the papilla acustica or organ of 
Corti, and extends " outward from the labium tympanicum or lower 
lip of the limbus to the outer wall of the cochlea, thus forming the 
tympanic or lower wall of the scala media, The limbus is the 
thickened epithelio-periosteum of the free edge of the lamina spiralis. 
The basilar membrane is composed of a tendinous basement mem- 
brane running from the lamina spiralis to the ligamentum spirale. 

The delicate membrane of Reissner, on the vestibular side, endo- 
thelium, and on the median side, epithelium, without basement 



438 



DISEASES OE THE NOSE, THROAT AND EAR. 



structure, rises from the upper surface of the inner side of the labium 
vestibuli of the limbus spiralis and extends at an oblique angle to 
the outer upper wall of the cochlear canal, forming the upper part 
or vestibular wall of the scala media. 

The scala media is a space included between the basilar membrane, 
the membrane of Reissner, and the ligamentumspirale. It is triangu- 
lar on section, and contains the papilla acusiica, which is formed by 
elongated neuroepithelial cells, furnished with long sensitive hairs. 



SCALA VESTIBULI 




t MEMBRANA 

REISSNERI 

^pt SCALA 

MEDIA 



«SL,LIGAMENTUM 
SPIRALE 



MEMBRANA BASILARI5 
ORGAN OF CORTI 



•SCALA TYMPANl 

Fig. 189. — Cross-section of First Whorl of Cochlea (magnified). 



These hair cells are connected with fibers of the cochlear nerve 
which passes from the modiolus through the lamina spiralis. 

The membrana tectoria is a mass of the delicate hairs which 
spring from the hair cells. This membrane is the most delicate 
tissue in the body, and cannot be treated by any reagents without 
great alteration. In most histological preparations the fibers are 
agglutinated and, detached from the hair cells, form a membrane 
with horizontal fibers attached to the limbus, while their outer 
margin comes into contact with the hair cells of the organ of Corti. 
Various manipulations of the specimens have given every conceivable 
variation of artifact. 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR. 439 

The auditory or eighth cranial nerve has a very complicated central 
course with many central connections. It is composed of two 
distinct parts differing in development, function, and histological 
characteristics, in origin, distribution, and arrangement of peripheral 
ganglia. One part of the auditory nerve, the cochlear nerve, 
conducts tone impressions. This nerve is distributed to the spiral 
ganglion at the base of the lamina spiralis. The peripheral ganglia 
of the nerve are in close connection with the sensory epithelium of 
the papilla acustica. The other part of the auditory nerve, the 
vestibular nerve, conducts sensations of motion and position in 




Fig. 190. — Vertical Radial Microscopic Section, Lamina Spiralis Ossea, Basilar 

Membrane and Papilla Acustica. 

a, Ganglion cells and cochlear nerve fibers; b, limbus lamime spiralis; c, auditory hairs; 

d, Papilla acustica; e, Basilar membrane; a-e, Scalatympani; b,c,d, Scala media. 

space and is distributed to the macula acusticce of the vestibule 
and the cristae of the semicircular canals. 

The cochlear and vestibular nerves are closely associated in the 
trunk of the eighth nerve. They lie exteriorly to the facial nerve in 
the internal auditory canal. The cochlear nerve lies below and 
in front of the vestibular. They accompany each other around the 
posterior border of the middle peduncle of the cerebellum, and in 
company with the facial nerve, wind round the restiform body and 
enter the pons Varolii at its lower border in a groove between the 
olivary and restiform bodies. 

The cochlear nerve fibers nearly all go to the opposite side of 
the brain, and are especially associated with the cortical centers. 



44Q 



DISEASES OF THE NOSE, THROAT AND EAR. 



They also have many motor connections for reflex movement, 
notably, with the nuclei for the motor nerves of the ocular muscles, 




third, fourth, and sixth cranial nerves. There is a direct connection 
with the nucleus of the facial nerve. 

The cochlear nerve fibers which pass to the colliculus inferior 



INNER EAR OR LABYRINTH AND NERVES OF THE EAR. 441 

are associated with fibers of the vestibular nerve, fibers from the 
optic thalamus, the superior cerebellar peduncle, the corpus genicu- 
latum internum, and the colliculus superior. In the colliculus 
superior the auditory tract is associated with fibers from the occipital 
cortex, the opthalmic tract, the anterior horn of the spinal cord, 
and with the fibers of the vestibular nerve. The auditory tract 
passes through the corpus geniculatum internum where it is associ- 
ated with fibers of the vestibular nerve and fibers from the optic 
tract. 

The auditory tract comprises the conduction, perception, concep- 
tion, and memory centers for sounds, and is intimately connected 
with the intellectual and emotional sphere, which is the highest 
development of the brain. Their functions depend for their exist- 
ence on language, and language is dependent fundamentally on the 
function of audition. 

The sensory auditory center is situated in the first temporal 
convolution and is continuous with the auditory memory center. 
It is connected with the auditory center of the opposite side and 
with the neighboring convolutions. 

(Lesions of the anterior portion of the auditory center are asso- 
ciated with sensory aphasia; those of the posterior portion with 
visual and speech difficulties, motor aphasia.) 

The auditory memory center is connected with the following 
centers of the same and opposite sides. 

The third frontal convolution, the motor speech center, motor 
vocal music center, motor vocal noise center; the second frontal 
convolution, writing speech center, dumb alphabet, writing music 
center, wordless sign center; the superior parietal convolution, tactile 
center for words and writing, tactile center for musical signs and 
instruments, tactile center for objects; angular gyrus, visual center 
for words, visual center for music, visual center for objects (sym- 
bolism); first, occipital convolution, visual center for objects. In 
right-handed persons the left hemisphere performs the functions 
connected with audition. 

Vestibular Nerve. Central Course. — The central origin and 
connection of the vestibular nerve are chiefly with the sensory and 
dynamic equilibrational and co-ordinational mechanisms, which 
bring the vestibular nerve into close relation with the cerebellum 
and nuclei for the motor nerves of the cranium, with the motor 



442 



DISEASES OF THE NOSE, THROAT AND EAR. 



tract of the spinal cord, and with the cochlear nerve. The vestibular 
nerve is also brought into close relation with the protective mechanism 
of the sympathetic nervous system through the vagus. The central 
distribution of the vestibular nerve is chiefly to the same side, very 
few fibers going to the opposite cerebellum. 

From Deiter's nucleus, the posterior nucleus, and the nucleus 
triangularis, the nerve runs direct to the cerebellum of the same 
and opposite side. Fibers of the vestibular nerve are connected 



OCCIPITAL CORTEX BY WAY OF 

BRANCHIUM QUADRIGEMINUM SUPERIORS 
AND RADIATIO OCCIPITO -THALAMIC 



OPTICAL TRACT 



CAL TRACT 



OCHLlEAR NERVE- OPPOSITE SIDE 
OCH/LEAR NERVE 
MENTUIYI 
PERIPHERAL /CEREBRAL SENSORY NURONS 




NUCLEUS 12 NERVE 



A PART OF CONNECTION OF 
SPINAL CORD AND 
NUCLEAJ OF CEREBRAL NERVES CEREBRUM , CENTRIPITAL 



AND CENTRIFUGAL 



CEREBELLUM 



CLEUS OF COCHLEAR NERVE 
OF SAME AND OPPOSITE SIDE5 
ARY BODY OF MEDULLA OBLONGATA 
OF SAME AND OPPOSITE SIDES 



VESTIBULAR NERVE 



SPINAL CORD- MOTOR NUCLEII OF 

CERVICAL NERVES IN SPINAL CORD 

NUCLEII OF NERVES OF HEAD AND BACK. 



Fig. 192. — Vestibular Nerve and Tract. 



with the sixth cranial nerve through Deiter's nucleus and the nucleus 
triangularis, and are brought into close relation with this nerve in 
the lemniscus lateralis. Vestibular fibers are brought into connec- 
tion with the optical tract through the corpus geniculatum, the 
tegmen and colliculus superior. They are brought into relation 
with the sixth nerve in the lemniscus lateralis, and with the fourth 
nerve of the opposite side in the colliculus superior; with the third 
nerve through the colliculus inferior. 

Vestibular fibers go from Deiter's nucleus to the motor nuclei 



NERVES ABOUT THE EAR. 443 

of the cervical nerves, nerves for the head, and back in the spinal 
cord of the same side. 

The vestibular fibers are connected through the lemniscus 
lateralis with the superior olivary body of the medulla oblongata 
of the same and the opposite side, with the ventral nuclei of the 
cochlear nerve of the same and opposite side, and with the tuberculum 
acusticum of the cochlear nerve of the opposite side. 

Vestibular fibers are brought into connection through the corpus 
geniculatum with the cochlear nerve of the opposite side, with the 
cortical auditory centers and with the colliculus inferior. 

Through the nucleus triangularr, the vestibular fibers are 
connected with the tegmentum of the opposite side. 

Fibers of the vestibular nerve are connected with the. occipital 
cortex by way of the brachium quadrigeminum superior and 
radiatio-occipital thalamic, and with the motor nuclei of central 
nerves and ventral horn of cervical cord of opposite side. 

Through the colliculus inferior the vestibule fibers are connected 
with the optic thalamus, with the cochlear nerve of the same and 
opposite side, with the brachium conjunctivum and with the 
inferior cerebellar peduncle. 

NERVES ABOUT THE EAR. 

Motor Nerve Supply. — The extrinsic muscles of the ear are 
supplied by the posterior auricular nerve, a branch of the facial, 
and by the anterior auricular nerve which comes from the right 
temporal, both branches of the facial nerve. The stapedius muscle 
receives its nerve supply from the stapedius nerve, a branch of the 
facial. The tensor tympani muscle is supplied by the tensor tym- 
pani nerve, made up in the otic ganglion from the maxillary division 
of the fifth nerve, from the facial nerve, through the great superficial 
petrosal nerve from the geniculate ganglion, through the spurious 
hiatus, anterior lacerated foramen, and Vidian canal to Meckel's 
ganglion, and also from the pterygopalatine nerves. The tensor 
veli muscle is supplied by the maxillary division of the fifth nerve 
through the otic ganglion; the retrahens tuba\ dilator tubse, or 
levator palati by the pharyngeal plexus and vagus nerve, through 
the superior palatine nerve and Meckel's ganglion, and by the faeial 
nerve through the great superficial petrosal. The vasoconstrictors 



444 DISEASES OF THE NOSE, THROAT AND EAR. 

of the ear are the sympathetic nerves. The chorda tympani nerve 
, of the seventh nerve, pars intermedia, is secretory, and supplies the 
submaxillary and sublingual salivary glands, and the sense of taste 
for the anterior half of the tongue. The chorda tympani nerve 
from the intermediary nerve of Wrisberg, accompanies the facial 
nerve to the stylomastoid foramen, and re-enters the bone through 
a foramen of its own, opening internally and anteriorly to the 
stylomastoid foramen. This nerve then passes through its canal 
and enters the tympanum, close to the posterior end of the annulus 
tympanicus and crosses the cavum between the long process of the 
anvil and the handle of the hammer. It passes out of the tympanum 
through the foramen or Huguier, parallel to the fissure of Glaser, 
to join the lingual nerve, a branch of the fifth nerve. 

Sensory Nerve Supply. — The auricle, upper part of the external 
canal and drum are supplied by the auriculo-temporal nerve, a 
branch of the fifth nerve. The posterior part of the auricle, the 
auricular muscles, and the auditory canal are supplied by the 
auricularis magnus, a branch of the third cervical nerve, and by 
the other branches of the cervical plexus. The cartilaginous meatus, 
the posterior wall of the bony meatus, and part of the posterior sur- 
face of the auricle are supplied by the auricular branch of the vagus, 
through the tympano-mastoid fissure. The tympanic cavity is 
supplied by the tympanic plexus, derived chiefly from the glosso- 
pharyngeus. The Eustachian tube is supplied by the tympanic 
plexus, together with the caroticotympanic branch of the small 
deep petrosal nerve, from the internal carotid plexus of the sym- 
pathetic, and also by the tympanic ( Jacobson's nerve) from the pet- 
rous ganglion. The tympanic plexus is formed by Jacobson's 
nerve, a branch of the glossopharyngeal nerve. This nerve divides 
over the promontory forming the tympanic plexus, one branch 
joining the carotid plexus of the sympathetic, while another, called 
the small deep petrosal, passes through a foramen in the tegmen 
to join the small superficial petrosal which connects with the facial 
nerve and through the otic ganglion with the fifth nerve. A third 
branch — the great deep petrosal — joins the great superficial petrosal 
which connects the facial and Vidian nerves, an efferent nerve coming 
from the Vidian canal and the posterior branch of the spheno- 
palatine ganglion. The chorda tympani nerve is the nerve of 
taste for the anterior half of the tongue. 



NERVES ABOUT THE EAR. 



445 



The Reflex Paths and the Temporal Plexus of Nerves. — This 
extensive nervous anastomosis admits of almost an unlimited 
variety of reflex motor, sensory and sympathetic phenomena. 



108 ABDUCtNS 




a 

Fig. 193.— Diagram of Nerve connection about the Ear, 
(1) Jacobson's nerve from the (2) petrous ganglion of the (3) glassapharyngeal nerve 
goes through Jaconson's canal in the jugular fossa, and passes into the tympanic cavity 
through a special foramen in the floor of the tympanum. It then forms the (6) tym- 
panic plexus on the promontory. (7) First branch of the tympanic plexus goes to the 
mucous membrane of the tympanum. (8) Second branch of the tympanic plexus'to 



446 DISEASES OF THE NOSE, THROAT AND EAR. 

the mucous membrane of the tympanum. (9) Third branch of the tympanic plexus 
going through a special foramen on the anterior surface of the petrous bone to form 
the (11) lesser deep petrosal which joins the (12) lesser superficial petrosal. (13) 
Fourth branch of tympanic plexus forms (14) greater deep petrosal, and leaves the ante- 
rior surface of the petrous bone through a small foramen a little behind the hiatus of 
Fallopius, and joins the (16) greater superficial petrosal. (17) Fifth branch of the 
tympanic plexus goes to the Eustachian tube. (18) Sixth branch of the tympanic 
plexus goes through a small foramen in the carotid canal and joins (20) sympathetic 
plexus of the internal carotid. (^21) Seventh branch of the tympanic plexus of the 
(22) chorda tympani nerve, which, as the (23) intermediary nerve of Wrisberg, accom- 
panies the (24) facial nerve as it enters the internal auditory canal, and follows the facial 
till it approaches the stylomastoid foramen, where the chorda tympani leaves the facial 
nerve and passes through the canal of the cord, emerging into the tympanic cavity 
through the posterior canal of the cord, passes through the tympanic cavity and 
leaves it through the anterior canal of the cord, or canal of Huguier. The chorda 
tympani nerve (22), after it has been joined by the seventh branch of the tympanic 
plexus (21) joins the (29) lingual branch of the (30) inferior maxillary branch of the 
(31) fifth cranial nerve. When the chorda tympani nerve (22) leaves the lingual (29) 
it forms the (32) submaxillary ganglion, which gives off branches: (2^) first branch 
of submaxillary ganglion to the (34) sympathetic plexus of the facial artery. (35) 
Second branch of the submaxillary ganglion to the submaxillary and sublingual glands. 

(36) Third branch of the submaxillary ganglion to outer half of tongue. The facial 
(24), together with the intermediate nerve of Wrisberg (23) (chorda tympani), and the 

(37) eighth cranial or auditory nerve, enter the internal auditory meatus. The facial 
nerve proceeds to the (38) geniculate ganglion, and gives off two branches through 
the hiatus of Fallopius, or through separate foramina; one branch, the greater super- 
ficial petrosal (16), the other, the lesser superficial petrosal (12), which joins the lesser 
deep petrosal (n) and sends a (40) branch. to the sympathetic plexus of the internal 
carotid (20). The lesser superficial petrosal (12) joins the (41) otic ganglion, which is 
connected with the inferior maxillary nerve (30) and gives off five branches; (42) 
First branch of otic ganglion to the (43) sympathetic plexus of the middle meningeal ar- 
tery. (44) Second branch of the otic ganglion to the (45) musculus tensor tympani. 
(46) Third branch of the otic ganglion joins the (47) auriculo-temporal nerve a branch 
with two roots from the inferior maxillarv (30). (48) Fourth branch of otic ganglion 
to (49) musculus tensor palati. (50) Fifth branch of otic ganglion to chorda tympani. 
(22) The greater superficial petrosal (16), a branch from the geniculate ganglion (38), 
joins the greater deep petrosal (14) which is a continuation of the fourth branch (13) of 
the tympanic plexus (6) and passes through a groove on the anterior surface of the 
petrous bone, and sends a (52) branch to the sympathetic plexus (20) of the internal ca- 
rotid artery, then forms the (53) Vidian nerve, and passes through the foramen lacerum 
anterium and the Vidian canal, and forms the (56) spheno-palatine, or Meckel's ganglion, 
with branches from the (57) superior maxillary branch of the fifth cranial nerve (31). 
The spheno-palatine ganglion sends a (58) branch to the (59) musculus levator palati. 
The fifth cranial nerve (31) is composed of a (60) sensory root, and a (61) motor root. 
The sensory root forms the (62) Gasserian ganglion, which has three branches: First, 
the inferior maxillary nerve (30) which is made up of a sensory nerve, and a motor 
root (61), which passes down through the foramen ovale. Second branch, the superior 
maxillary nerve (57) and (64) third branch, the ophthalmic division of the fifth cranial 
nerve. A branch of this, the (65) nasal nerve, joins the (66) ciliary ganglion of the 
67) third cranial nerve. The inferior maxillary nerve (30), first branch of the Gasserian 
ganglion (62), gives off two branches, the (68) upper branch and the (69) lower branch, 
which unite to form the auriculo-temporal nerve (47). This nerve has two branches (70 
and 71) to the tympanic membrane. The auriculo-temporal nerve (47), sends a (72) 
branch to the temporo-maxillary articulation and (73) a superior auricular branch to 
the skin of tragus and pinna. The auriculo-temporal (47) gives a branch (74), 
the anterior temporal nerve, to the temporal region. This has (75) a branch which 
joins the (76) orbital branch of the superior maxillary nerve (57) and has another (77) 
branch which communicates with the facial nerve (24). (78) The inferior auricular 
branch of the auriculo-temporal, (47) supplies the ear below the external meatus and 
sends a (79) branch to the sympathetic nerve of the internal maxillary artery, and (80) a 
branch of the auriculo-temporal (47) to the parotid gland. The auriculo-temporal has 
another branch, (81) the posterior temporal to the upper part of the pinna, an (82) anas- 
tomosis of the auriculo-temporal (47) and the facial (24) nerves in front of the cartilag- 



NERVES ABOUT THE EAR. 447 

inous meatus. Facial nerve (24) leaves the geniculate ganglion (38) giving off (83) 
a branch to the (84) musculo stapedius (85), a branch to the facial nerve from (86) 
Arnold's nerve, which passes through a small foramen in the jugular fossa from (87) 
the pneumogastric. The facial nerve (24), after passing through the stylomastoid 
foramen, joins the auriculo-temporal nerve (47) through the anastomosis (82) and 
has a branch, (88) the posterior auricular, which is distributed to the superior part of 
the cartilaginous canal and some of the posterior surface of the auricle The posterior 
auricular nerve joins (89) the auricular branch of the pneumogastric (87) or a branch 
of Arnold's nerve (86). These nerves anastomose on the posterior wall of the canal 
through (90) a branch with (91) the auricularis magnus, a branch from the (92) second 
cervical nerve and (93) third cervical nerve. The auricularis magnus (91) has three 
branches: (94) first branch to the face communicates with the facial nerve (24) 
through (102). (95) Second branch to the posterior part of the meatus and auricle 
communicates with the auricular branch (88) of the facial (24) through (103) and 
communicates with the pneumogastric (87) via (89) through (104). (96) Third 
branch to the mastoid and integument behind the ear, communicates through (105) 
with the auricular branch (88) of the facial (24). The glossopharyngeal nerve (3) 
and the pneumogastric nerve (87) pass through the foramen rotundum. The pneu- 
mogastric nerve (87) forms (98) the ganglion of the root which sends off (99) a branch 
which unites with (100) a branch from the petrous ganglion (2) to form Arnold's 
nerve (86). The petrous ganglion (2) and the pneumogastric ganglion of the root (98) 
are connected by (101) nerve fibers. Anastomosis of the facial branch (94) of the auric- 
ularis magnus (91) with the facial nerve (24). (103) Communicating branch between 
the posterior branch (95) of the' auricularis magnus (91) and the auricular branch (88) 
of the facial (24). (104) Connecting branch between the posterior branch (95) of the 
auricularis magnus (91) and the auricular branch (89) of Arnold's nerve (86) from the 
pneumogastric (87). (105) Communication between the mastoid branch (96) of the 
auricularis magnus (91) and the posterior auricular branch (88) of the facial nerve (24). 
(106) Sixth cranial nerve (abducens). (107) Communication of the sixth (106) nerve 
and the spheno-palatine ganglion (56). (108) Communication of the sixth nerve (106) 
and the ophthalmic division (64) of the fifth nerve (31). (109) Communication of the 
sixth nerve (106) and the carotid plexus (20). (no) External petrosal from genicu- 
ate ganglion (38) to meningeal plexus (43). 

The temporal plexus of nerves, or the plexus of nerves associated 
with the ear, contains a complicated network of sensory, motor, 
and sympathetic nerve fibers with nervous ganglia and plexiform 
anastomoses between the III (motor oculi), V (trigeminus), VI 
(abducens), VII (facial), X (pneumogastric), and XII (hypoglossal) 
cranial nerves and the cervical plexus and the sympathetic of the 
arterial and venous plexuses, thus connecting the cranium, face, 
throat, neck, circulatory sympathetic plexus, gastric, pulmonary, 
and cardiac nerves. 

Common motor and sensory reflexes occur through the third, 
fifth, seventh, ninth, and tenth cranial nerves, and through the 
sympathetic nerves. Ear stimulations give rise to motor oculi 
disturbances through the third nerve, including ciliary reflexes. 
Saliva and tear disturbances occur through the fifth nerve; spasmodic 
facial reflexes through the seventh nerve; spasmodic pharyngeal 
reflexes through the ninth nerve. Disturbances of the Larynx, 
heart, and stomach occur through the tenth nerve. 

Vasomotor disturbances take place through the sympathetic 



448 DISEASES OF THE NOSE, THROAT AND EAR. 

nerves. Aurotrophic reflexes coming toward the ear cause motor 
disturbances, which give rise to tinnitus. They come from the 
fifth nerve, affecting the tensor tympani muscle, and from the 
seventh nerve, affecting the stapedius muscle. Reflex pain sensa- 
tions come to the ear through the fifth nerve from the teeth and 
gums; through the ninth nerve from the pharynx; through the tenth 
nerve from the larynx. Reflex pain emanating from the ear 
affects the teeth and dura mater through the fifth nerve. Reflexes 
from the ear through the ninth and tenth nerves cause choking 
and coughing. The sympathetic nerve is affected by or affects 
the ear reflexly. The ear is affected by reflex congestion or anemia, 
causing trophic and sensory phenomena (tinnitus). The ear 
influences the cerebral circulation through the carotid plexus, and 
causes anemia or hyperemia of the brain. 

ANATOMY OF THE INFANT'S EAR AND SUBSEQUENT 

DEVELOPMENT. 

The sense of hearing does not appear until the fourth day after 
birth. This sense is the last one to appear and the slowest to develop. 
Not until the fourth month can we ascertain that the child has normal 
hearing. 

At birth the temporal bone is loosely connected with the other 
cranial bones. At this period the temporal bone is soft and spongy 
except the capsule of the labyrinth which, even now, is dense bone. 
The temporal bone gradually forms dense cortical layers, which at 
the close of the first year, are thin but quite solid. At first the 
temporal bone is very vascular and is traversed by many canals 
containing vessels which allow very free circulation of the blood 
between all the surfaces of the bone. The chief of these is the petro- 
squamosal foramen. The temporal bone can readily be divided into 
its petromastoid and squamo-tympanic parts, which are separated 
by wide sutures. The annulus tympanicus is firmly attached by 
its apices to the outer plate of the squamous bone. The petro- 
mastoid portion is still separated from the squamous by a cartilag- 
inous plate, and the petrotympanic suture is wide open. Before 
the end of the first year, however, all the parts are united. 

In the new-born infant, the mastoid antrum, measured from the 
tip of the short process of the incus, is about 8 mm. in length; the 



ANATOMY OF THE INFANT S EAR. 



449 



adult antrum, measured in the same way, is about n mm. In the 
infant the walls are of spongy bone, and the outer wall, made up by 
the posterior process of the outer plate of the squama, is softer and 
thinner than the tegmen. (This fact explains the readiness with which 
pus escapes in this direction in infancy.) The mastoideo-tympanic 
suture is not united, and therefore allows subperiosteal escape of pus 
from the tympanum behind the posterior wall of the meatus. The 
mastoid process is not yet formed, but its future site is indicated by 



SQUAMA 




PETRO-SQUAMOSAL 
SUTURE 

INCI5URA 

RIVINI 
ANVIL 
SPINATYMPANT 

POSTERIOR 



STIRRUP 

riNUS TYMPANICU: 

» .YLO-MASTOID FORAMEN 



■TEMPORAL FOSSA 
ZYGOMA 



GLENOID F05SA 



SPINA TYMPANI 
MAJOR 



ROUND WINDOW 

PROMONTORY 



FISSURE OF. GLASER 

OCESSUS COCHLEAR IS 
TUBE 



ANNULUS TYMPANICUS 



CAROTID CANAL 
GROOVE TYMPANIC PLEXUS 



Fig. 194.— Outer View of Right Temporal Bone at Birth (enlarged)! 



a flat tubercle. The development of the mastoid process begins 
about the second year, after which it grows chiefly from an increase 
of diploe till near the time of puberty, when it grows rapidly and the 
air cells are completely developed. At birth the upper part of the 
antrum may be encroached upon by trabecule enclosing cells. 
Small cells may appear in the base of the process as early as the 
third year. The groove for the sigmoid sinus becomes noticeable 
about the end of the first year, and its development is also completed 
at puberty. At birth, the sigmoid sinus is always placed well 
behind the tympanum and never approaches the meatus. The 
bone between the sigmoid sinus and the mastoid antrum is compara 
tively thick. 
29 



45° 



DISEASES OF THE NOSE, THROAT AND EAR. 



When the infant is born, the lower and outer walls of the facial 
canal are wanting where the canal crosses the tympanum above 
the oval window. The stylomastoid foramen, for the exit of the 



PETRO-SQUAMOSAL 
SUTURE 



PETRO-MfcSTOiD 

EMINENCE POST. 
SEMICIRCULAR 
CANAL 




EOMEN TYMPANI 

ANTERIOR 
SEMI-CIRCULAR 
CANAL EMINENCE 

CAROTID CANAL 
FOSSA SUBARCVATA 



INTER. AUD. MEATUS | 

X3UAEDUCTUS COCHLEAE. 

-AQUAEDUeTUS. VESTiBULI 
JUGULAR SURFACE r^i 

Fig. 195. — Inner View of Left Temporal Bone at Birth 



facial nerve, lies immediately behind the annulus tympanicus on the 
lateral surface of the temporal bone, not on the under surface as 
in the adult. This foramen is not deep beneath the tissues of the 
neck, as in the adult, but is superficial. The exposed position of the 



HIATUS FALLOPIUS 



GROOVE FOR SUPERFICIAL 
PETROSAL NERVES 

DEPRESSION FOR 
OASSERIAN GANGUOl 
MUSCULAR CANAL. 

CAR.OTID 
CANAL 



PROCESS 1 PROMINENCE EXTERNAL 

COCHLEARIFORMf SEMI- CIRCULAR CANAL 

SPINA TEG MEN IS/ TEG MEN ANTRl 

I TEG MEN TYM PAW ^ AD ITU 5 

ANTRUM 



DEFECT IN 
FACIAL 
CANAL 




ROUND WINDOW 
PROMONTORY 
GROOVE OF TYMPANIC PLEXUS 



STYLO- MASTOID 
FORAMEN 



MASTOID TUBERCLE 
STAPES TEN DEN FORAMEN 



Fig. 196. — Left Petromastoid Bone at Birth, Outer Side. The Squamo-tympanic 

Bone has been Removed. 



facial nerve at its exit from the stylomastoid foramen in the infant 
makes it especially liable to injury in the mastoid operation. There 
is no styloid process or digastric groove at birth. 



ANATOMY OF THE INFANT'S EAR. 



451 



The osseous Eustachian tube is also wanting in the infant. The 
tympanic cavity is about as extensive as in the adult, measuring 
14 mm. parallel to the malleus handle. Sieve-like bone separates 
the floor of the tympanum from the carotid canal, and from the 
jugular bulb which is located directly below, and not behind the 
tympanum. The jugular fossa is not yet formed. The oblique 
position of the meatus and this thin plate of bone allows a puncture 
of the jugular bulb or carotid artery during tympanotomy. The 
osseous labyrinth, the ossicles, and the sulcus tympanicus are fully 



5QUAM0-PETR05AL 
SUTURE 
SPINA TEGMENIS 
TEGMEN TYMPANI 
ANTERIOR SEM1-CIRC.- CANAl- 
CANAL VESTIBULAR NERVE 
5EC0ND TURN COCHLEA^ 
PORU5 ACUSTICUS, 
INTERNAL — 
AUDITORY MEATUS 

LAMINA SPIRALIS 



FIRST TURN 
COCHLEA 

CANAL CAROTID 
ARTERY 



PROMONTORY 




PROCESSUS 
COCHLEAR IS 



GLASERIAN FISSURE 



GLENOID FOSSA 
EUSTACHIAN TUBE 
SULCUS TYMPANICUS 



Fig. 197. — Vertical Section through the Meati, Anterior Half, Right Temporal 
Bone at Birth (enlarged). 



developed, and, together with the facial canal, are in their permanent 
relative positions. The cavum tympani changes very little after 
birth, but its accessory cavities, the mastoid cellular system and the 
Eustachian tube, undergo development. The tympanic muscles 
also grow much larger. 

The osseous external auditory meatus does not exist at birth, and 
the suprameatal spine has not yet been developed. During the 
second year the tubercles of the annulus tympanicus enlarge suf- 
ficiently to meet and enclose the foramen of Huschke in the tympanic 
plate, which gradually closes and is usually obliterated after the 
fifth year. Development of the whole temporal bone is complete 
soon after puberty. 



45 2 



DISEASES OF THE NOSE, THROAT AND EAR. 



The external auditory meatus measures at birth about 13 mm. on 
the upper wall and 19 mm. on the lower; the adult meatus about 



PETRO'MASTOID 



PETRO- SQUAMOSAL 
SUTURE 

SQUAMA 
CRISTA TEGMENIS 

ADITUS AND 
PROMINENCE 
EXT. CIRC. CANAL 
PROMINENCE 

FACIAL CANAL 
SELLA INCUDI3 
POSTERIOR CANAL 
OF THE CHORD 

FORAMEN STAPEDII 

5TAPE3 

SINUS TYMPANICUS 

PROMONTORY 

ANNULUS TYMPAWCU&- 




TEGMEN ANTR1 

TEQMEN TYMPANI 

PROMINENCE ANTERIOR 
SEMI-CIRCULAR CANAL 

ANTERIOR SEMI- CIRC. CANAL 
„ AMPULLA ANT. 5EMI-C.CAN. 
AMPULLA EXT. 5EM1-C, CANAl 
FORAMEN 5YBARCUATUM 
VESTIBULE 
POSTERIOR 5EM<-CIR. CANAL 

FACIAL CANAL 
INTERNAL AUDITORY CANAL 

FACIAL CANAL. 
— COCHLEAR FORAMJNA 
LAMINA 5PIRALIS OSSEA 
FIRST TURN COCHLEA 

CAROTID CANAL 

PETRO -TYMPANIC 5UTURE 

SULCUS TYMPANICUS 



Fig. 



-Same Bone as in Fig. 46, Posterior Half (enlarged). 




HEAD OF HAMMER 
EXTERNAL 
AUDITORY MEATUS 

TENDON 
TENSOR TYMPANI 

MANUBRIUM 
ATRIUM 
MEMBRANA TYMPAN 



DURA MATER 
-TEG MEN 

'SUSPENSORY LIGAMENT OF MALLEUS 
-ATTIC 

INTERNAL AUDITORY 
CANAL 
FACIAL NERVE 

FIRST TURN 



OF COCHLEA 



Fig. 199. — Vertical section of ear through meati; anterior half, left ear, infant. Shows 
the external meatus extending upward and outward; the hammer is cut across the neck, 
and a piece of the handle is seen in the membrane (enlarged). 

29 mm. and 35 mm., respectively. The meatus is not closed by 
agglutination of its walls as in the young of lower animals, but there 
is a simple coaptation of the inferior and superior wall and the 



ANATOMY OF THE INFANT'S EAR. 



453 



membrana tympani with the inferior wall. The irregularities 
are filled with desquamated epithelium, consequently the lumen 
or air space of the meatus does not exist. In a few days after birth 
the meatus begins to open gradually, forming an hour-glass-shaped 
canal with a constriction corresponding to the isthmus of the canal 
of the adult. This canal, which is large at the inner end to fit 
the size of the annulus, retains foreign bodies with more tenacity 
than the adult meatus. The axis of the external meatus is directed 



DURA WATER 



SQUAMA 



MEATUS AUDIT0RIU5 
EXTERNU5 




CAROTID 
ARTERY 



MANUBRIUM MALLII 



MEMBRANA TYMPANI 
ATRIUM 



Fig. 200 — Vertical section of ear through meati, posterior half, left ear, infant. 
Shows the body of the incus cut, the tip of the handle of the malleus in the membrane; 
stapes in the oval window (enlarged). 



slightly downward, which necessitates downward traction on the 
auricle to allow inspection of the membrane, and thereby causes 
the illusion that the membrane lies horizontally. At birth half 
the meatus is cartilaginous and half membranous. 

In the infant the attachment of the auricle to the side of the 
head is proportionately more extensive than in the adult, thus placing 
the angle formed by the pinna and the side of the head far back- 
ward. The difference in position may be the cause of accidentally 
opening the fossae of the skull, mistaking these for the antrum which 
lies anteriorly. 

The Eustachian tube is narrower and much shorter in the infant 



454 



DISEASES 01 THE NOSE, THROAT AND EAR. 



than in the adult. It measures about 20 mm. and in the adult about 
40 mm. from the anterior border of the sulcus tympanicus. Its 
lumen at the isthmus is about half that of the adult tube, measuring 
about 2 mm. against 4 mm. in the adult. Unlike the adult tube, 
it lies in a horizontal plane, but its angle with the median plane is 
about 45° forward and outward, as in the adult. The tube assumes 
the adult position at puberty. The relative position of the pharyn- 
geal orifice as regards the posterior pharyngeal wall and velum 
palati is farther forward and slightly lower down in the infant than 



GROOVE FOR TEMPORAL 
ARTERY 



TEMPORAL Rl 



PROMONTORY 



Digastric groove. 




.cyGOMA 
GLEK010 FOiSA 

fissure of glas er 
tym pano-pharyngeai.- 

TUBE 
CAROTID CANAL 



STYLO -MASTOID FORAMEN 



— FORAMEN OF BUSCHKE 
TYMPANIC PLATE 

JUGULAR FOSSA 

STYLOID PROCESS 



Fig 2Ci. — External View of Right Temporal Bone of Infant One Year Old. 



in the adult. The fossa of Rosenmiiller does not appear as a deep 
depression until later in life. 

The tympanic air cavity does not exist at birth, the osseous 
cavity being filled with myxomatous tissue and cellular detritus. 
It is not formed until several days later, when the air enters through 
the Eustachian tube. Still later, the air takes the place of the myx- 
omatous contents of the mastoid antrum. The mucosa lining the 
cavum tympani and antrum has a very thick submucous layer, and 
in the cavum. a very uneven surface. The thickness of the submu- 
cous lining and the reduplication of the membrane cause considerable 
reduction in the size of the tympanic cavity and the mastoid antrum. 
In general, the tympanic cavity and mastoid antrum of the infant 
contain much more mucous membrane and more bonv trabecular 



PHYLOGENESIS. 455 

than those of the adult. In the adult these are reduced by an 
atrophic process. The contents of the tympanum proper are fully 
developed at birth. The drum membrane at birth is the same 
size as in the adult. 

It is worthy of note that the lymphatics of the infant show a 
more important difference in comparison with those of the adult 
than any of the other structures. It is peculiarly significant that the 



WORMIAN BONE 
IN THE PARIETAL 
^-a^ NOTCH 



EXTERNAL ^j 

auditory meatus . 
non-ossified area of 

the tympanic plate " 
petro-tympanic fissure- 



Fig. 202. — Temporal Bone at the Sixth Year (Morris). 

infantile lymphatics are nine times more permeable than those of 
the adult. The length of the lymphatics from the ear to the 
mediastinum in the infant is about one-ninth that of the adult lym- 
phatics— 2.5 cm. to 18 cm. The caliber, however, is the same. 
These dimensions allow the transmission of bacteria to the media- 
stinum nine times more readily than in the adult. 

PHYLOGENESIS. 

The phylogenesis of the vertebrate ear shows clearly that the ear 
of man is a development of the undifferentiated ectoderm, which 
was the primitive organ of sense. The perception of sound begins 
by being merely the general tactile or pressure sense-perception of 
vibration. (This tactile appreciation of sound is not lost throughout 
the zoological series, not even in man.) 

The Morphological Development of the Labyrinth.— Certain portions 



456 DISEASES OF THE NOSE, THROAT AND EAR. 

of the sensitive ectoderm became differentiated for the purpose of 
more highly-developed perception of certain stimuli, such as the 
molar movements of the circumambient water. This part of the 
skin then became the lateral line canal organ of the fish. This 
canal organ becomes still further specialized for the perception of 
molar motion by the development of neuro-epithelium, and by add- 
ing sand particles to the water in the canal. These sand particles 
impinge more forcibly on the hairs of the neuro-epithelium than 
could the water. The sand particles also furnish a means for the 
perception of the direction of gravitation. This canal organ develops 
into the primitive labyrinth. The first change of this canal organ 
is a specialization of part of the canal which retains openings at 
both ends to the surrounding water. This tube develops a pouch, 
and divides into the utricle and saccule, each half developing semi- 
circular canals, which are always at right angles to each other. The 
utricle and saccule retain the original external openings of the canal, 
which become the endolymphatic ducts. Later, the utricle loses 
its endolymphatic duct. Still further on. in the series, the saccular 
duct becomes closed externally, and calcareous concretions, called 
otoliths, take the place of the original sand otoliths. 

Functional Development of the Labyrinth. — The primitive labyrinth 
had an undifferentiated power of perception of molar and molecular 
motion. The organ for the perception of molar motion became 
more highly specialized, forming the peripheral organ of equilibra- 
tion, which is situated in the vestibule and the semicircular canals. 
In the higher reptiles. the differentiation of a portion of the labyrinth 
appeared for the better perception of the molecular or sound motion. 
Thus was developed the legena, the parent of the cochlea. The 
cochlea still retains the characteristic of being a pressure organ. 
As the labyrinth becomes differentiated and specialized in its struc- 
ture, the otoliths are less extensively distributed, and the sensory 
epithelium or hair cells become less numerous, but more highly 
differentiated. 

It is interesting to note that the peripheral space organ, or the 
organ of equilibration is formed on the same plan throughout 
the animal series, namely, that of a sensitive sac containing one 
or more otoliths. The only important variation is the source and 
number of these otoliths. In most cases, these bodies are found 
in a closed sac; in some species, as in the lobster and spiny dog- 



PHYLOGENESIS. 457 

fish they are fine particles of sand placed in specialized cups by 
the creature itself. 

■Development of Perilymphatic Sac. — The perilymphatic sac is 
developed from the large lymph spaces surrounding the lateral line 
canal. The legena organ is highly developed among the alligators 
and crocodiles, and more highly in the birds. The cochlear 
development of the legena does not appear until we reach the mam- 
mals. The cochlea is the only part of the ear which serves for sound- 
perception alone. 

Development of the Tympanum. — The drum membrane and its 
ossicular connection with the labyrinthine fluid were made necessary 
when the animal became an air-breathing amphibian, in order to 
facilitate the difficult transmission of sonorous vibrations from the 
rarer medium of the air to the denser medium of the labyrinthine 
fluid. The ossicular connection traverses a space called the cavum 
tympani. The number of ossicles varies from one to three. Their 
proportionate size and the shape of the cavum varies in different 
genera. 

The air space of the tympanum was at first made to provide space 
in which the drum membrane could vibrate. In the lower types, 
these spaces did not extend beyond the membrane, and the ossicular 
connections were covered by mucous membrane. There were no 
air cells, such as the mastoid cells. Later on, the mucous membrane 
became less abundant, and cells were developed communicating with 
the tympanic cavity. The ossicles were more or less free in the 
cavum tympani. In man, the ossicular chain seems to be under- 
going a change from being partially covered to being wholly free 
from the folds of mucous membrane. 

Development of the External Ear. — The auricle is a device for col- 
lecting aerial sound waves, and this mechanism first appears in the 
terrestrial mammals. In man the auricle is a degenerate organ, 
inasmuch as it has lost all practical power of motion in order to 
collect or locate sounds. The muscular apparatus is usually present . 
but is functionally deficient. In many of the lower animals the 
auricle has considerable mobility which enables its possessor to 
collect a greater volume of sound and to determine its direction. 

Not until we reach the mammals do we find the essential type 
of the human labyrinth with its three semicircular canals, utricle. 
saccule, and cochlea, and the external canal and auricle. 



458 DISEASES OF THE NOSE, THROAT AND EAR. 

EMBRYOLOGY AND ONTOGENY. 

The otic vesicle, which later forms the endolymphatic structure, 
develops at an early age from the ectoderm at the dorsal termination 
of the first visceral cleft. The counter of the complete endolymph- 
atic sac is formed by the growth of special parts of the original 
vesicle, by infolding, and by the disproportionate rate of development 
of the walls. The cochlea, which begins as a short pit, becomes 
elongated and curves into a spiral. The n euro-epithelium is formed 
by a special development of certain areas of the epithelium lining 
the otic vesicle. The perilymphatic sac is formed from enlarge- 
ment of the lymph spaces surrounding the endolymphatic sac or 
the vesicle. 

The acoustico-facial ganglion is developed on the dorsum of 
the hind brain, close to the otic vesicle. The ganglion first divides 
into the facial and acoustic ganglia. The acoustic ganglion, in 
turn, subdivides into two ganglia, one connecting with the neuro- 
epithelium of the cochlea and the other with the neuro-epithelium 
of the vestibule and semicircular canals. The enveloping petrous 
portion or the labyrinth capsule is developed from the mesoderm, 
which surrounds the otic vesicle. 

The tympanic cavity and its appendages are formed from the en- 
dodermal layer of the first visceral cleft, by evagination and by 
increased development of certain parts. The mesodermal layer 
surrounds this evaginated cavity. The hammer and anvil are 
formed from the first visceral arch which also forms part of the 
tympanum. The stirrup and the stapedius muscles are developed 
from the second visceral arch. This arch meets with the first to 
form the roof of the tympanic cavity. 

Near the end of fetal life the mucosa of the pharynx follows 
the spaces left by spongification and absorption of the matrix about 
the ossicles and covers these spaces and the other tympanic structures 
with mucous membrane. The mastoid antrum and later the mastoid 
cells are formed by evagination of the mucous lining. The tympanic 
membrane and external ear are formed from the ectodermal groove 
of the first branchial cleft. The ectodermal layer of the external 
meatus is evaginated inward and the endodermal layer of the 
middle ear outward. The drum membrane is formed at the place 
where these layers meet. 



author's bibliography. 459 

The pinna is developed from the posterior edge of the first, 
and the anterior edge of the second branchial arches. The centers 
or ossification for the different parts are quite numerous. Shortly 
before birth the bony structure is composed of three parts — the 
petromastoid, squamous, and tympanic or annular tympanicus. 

AUTHOR'S BIBLIOGRAPHY. 

The Anatomy of the Child's Ear; emphasizing points of practical importance. 

Archives of Otology, New York, April, 1905, vol. xxxiv, No. 2, p. 80-83. 
The Eustachian Tube, its Anatomy and its Movements; with a description of the 

cartilages, muscles, fasciae, and the fossa of Rosenmuiler. Medical 

Record, New York, June 8, 1907, vol. lxxi, No. 23, pp. 931-934. 
Anatomy of the Ear; Dr. C. H. Burnet's System of Diseases of the Ear, Nose 

and Throat. J. B. Lippincott, Phila., 1893, vol. i, Part 1, pp. 1-82. 
Observations on the Topography of the Normal Human Tympanum. Archives 

of Otology, New York, 1890, vol. xix, No. 4, pp. 217-231. Bemerk- 

ungen zur Topographie der normalen menschlichen Paukenhohle. Zeit- 

schrift f. Ohrenheilkunde, Wiesbaden, 1891-92, vol. xxii, No. 2, pp. 91- 

102. 
Reduplications of Mucous Membrane in the Upper Portion of the Tympanic 

Cavity and their Clinical Importance. Boston Med. and Surg. Jour., 

1889, vol. cxx, No. 22, pp. 531-533. 
Doublements de la Membrane Muqueuse dans la Partie Superieure de la 

Cavite Tympanique, etc., Annales de Mai. de l'Oreille, du Lar., etc., 

1889, vol. xv., No. 8, pp. 454-458. 
La Trompe d'Eustache, son Anatomie et son Appareil Moteur avec Description 

du Cartilage, etc., Archives Internat. de Laryn., d'Otol. et de Rhinol., 

xxvi, No. 4, July-Aug., 1908, p. 291. 



CHAPTER XXVI. 

PHYSIOLOGY. THEORY OF SOUND PERCEPTION. TONE AND NOISE 
PERCEPTION. PHYSIOLOGY OF SOUND CONDUCTION. PHY- 
SIOLOGY OF THE DETERMINATION OF THE DIRECTION OF 
SOUND. TACTILE SENSE OF SOUND PERCEPTION. 
PHYSIOLOGY OF EQUILIBRATION, PROTECTIYE 
MECHANISM OF TFIE EAR. 

THEORY OF SOUND PERCEPTIOX. 

In the fourth century, B. C, Empedocles referred the auditory 
impressions to the cochlea. From his time until the time of Helm- 
holtz there was no marked advance in the theory of sound percep- 
tion, the general explanation of the phenomenon being on a tactile 
or pressure basis. 

Helmholtz found a very fertile suggestion for a basis of his theory 
of sound perception by sympathetic vibrations in the description 
of the cochlea as a sound-perceiving mechanism with a basilar 
membrane containing fibers, whose length varied successively, 
from the longest at the apex of the cochlea to the shortest at its base. 

This explanation of the arrangement of the basilar fibers, which 
was made by Hensen, Helmholtz made the foundation of his final 
theory, which is called the " piano-string theory " of sound perception. 
His theory is, briefly stated, that each basilar fiber responds sym- 
pathetically to a definite tone, and stimulates the hair cell of the 
neuro-epithelium of Corti's organ which rests upon the fiber; and 
that the nerve impulse from this stimulation of the hair cell is 
carried to the brain as a stimulation of a definite cell corresponding 
to a definite note. The higher tones, according to Helmholtz, 
are perceived at the base of the cochlea, and the lower tones at its 
apex. 

The objections to this resonance theory of Helmholtz are: 

The phylogenetic development of the mammalian ear from the 
lowest vertebrate ear shows nothing of a sound-selecting device 
corresponding in any way to Helmholtz' s supposition with regard 
to the human cochlea. 

460 



THEORY OF SOUND PERCEPTION. 461 

The next objection is an anatomical one, namely, that there are 
not enough fibers and they are not of the various relative sizes 
required to respond to all audible notes. The structure of the basilar 
membrane is a basement aponeurotic membrane with fibers running 
transversely and longitudinally, and covered with relatively thick 
masses of cellular tissues and blood-vessels. Fibers in such a mass 
could not vibrate individually, and therefore could not vibrate 
sympathetically to any tone. 

The so-called sensitive hair theory seems to the author to be the 
most plausible and most satisfactory explanation of the phenomenon 
of sound-perception. Briefly stated, the theory is: A sound wave 
after it has been transmitted through the external and middle ear, 
and has entered the labyrinthine fluid, beats upon the sensitive 
hair band, formerly called the tectorial membrane. These long 
sensitive hairs appear to the author to be the means of the transmission 
of the sound wave impulses to the neuro-epithelial cells. The sound 
waves pass over these sensitive hairs in much the same way as wind 
passes over a corn field. The motion of the hairs thus caused is 
transmitted down the hair to the neuro-epithelial hair cell which 
transforms it into a nerve motion and the perception takes place 
in the higher centers of the brain, the sound waves not being analyzed 
in the cochlea as is generally supposed. 

This sensitive hair-theory is based on the phylogenetic and onto- 
genetic development, and upon the histological structure of the 
organ of Corti. 

Let us first consider the phylogenetic development of the organ 
of Corti. 

The organ of sound-perception, or the organ of Corti, is merely 
a specialized portion of the general tactile sense organ of the lowest 
vertebrates, without any special sound-selecting power. 

In the tunicates, and even in the lowest of the vertebrate series, 
the tactile sense alone perceives molar and molecular motion of the 
surrounding aqueous medium. The first advance toward a dif- 
ferentiation of function appears in the fishes where the lateral line 
canal organs first appear. These organs are formed by invagination 
of the cuticular layer and are provided with clumps of specialized 
sensory epithelium. Because of this specialized epithelium and 
because of the canal form, these organs have a more highly developed 
power of noting the molar and molecular movements of the cir- 



462 DISEASES OF THE NOSE, THROAT AND EAR. 

cumambient aqueous medium than the undifferentiated surface of 
the body. 

There is very strong evidence to justify the statement that, as 
specialization advances in the ascending series, a part of this canal sys- 
tem is set apart and endowed with still more delicate and specialized 
power of molecular movement-perception, a definite tone-perception. 
This change is brought about first by the separation and enclosure 
within the head of a specialized portion of the canal organ which 
has now become a labyrinth. 

The legena first appears in the fishes. The labyrinth is further 
specialized in the higher reptiles and birds by the greater develop- 
ment of the legena with its papilla basilaris. Still further specializa- 
tion takes place in the mammals by the development of the legena 
into the cochlea with its organ of Corti. 

To go back to the primitive condition of the lateral line canal 
organ, we observe that certain of the epithelial cells are specialized 
and furnished with filaments or hairs which facilitate the perception 
of the molar and molecular motion of that part of the circumambient 
fluid which circulates in the canals. This hair-bearing epithelium 
persists throughout the vertebrate series, changing only in grouping 
and in its increasing specialization, and continues to be bathed by 
the fluid which in the higher forms is enclosed within the labyrinthine 
capsule. The function of the epithelium also continues to be the 
same, except for the specialization of certain groups of the hair- 
bearing epithelial cells adapted to the perception of special forms 
of molar and molecular motion. The epithelium that concerns 
us in sound perception, while it is specialized for the perception 
of molecular wave-motion or sound vibrations, has not lost its 
primitive type. 

The ontogenetic development of the organ of Corti proceeds along 
parallel lines to the phylogenetic development. 

Histological Structure of the Organ of Corti. — There are several 
highly specialized portions of the labyrinth of the higher vertebrates 
which have long baffled investigators and have long been subject 
to misinterpretation. The organ of Corti alone concerns us as 
specialized for sound perception, but by the help of the others, 
we can make our point clearer. 

In mammals, the epithelium of the cristas and the maculae acusticae 
are provided with long hairs. For a long time the relation of the 



THEORY OF SOUND PERCEPTION. 463 

hair and the hair cells of the cristas and the maculae acusticae in 
the lower forms was misunderstood, owing to the condition in 
which the histologists found the hairs. They appeared transformed 
into a mass which at first was called a tectorial membrane or 
"cupola" from its shape. Finally it was proved that the tectorial 
membrane or cupola was really made up of the bulk of the hairs of 
the neuro-epithelium, and that the reagents employed in the manipu- 
lation had made this artifact of them. More recently it has been 
proved that the tectorial membrane of the papilla basilaris legenae 
in reptiles and birds, and later still the tectorial membrane of 
the organ of Corti in mammals, are artifacts similar to the cupolas, 
and really are an amalgamated mass of hairs of the neuro-epithelium. 
These structures have been shown to be extremely susceptible to 
alteration from chemical reagents. The distorted appearance of the 
hairs making up the tectorial membrane and the errors in the 
observations were due to the fixing and staining reagents to which 
they were submitted. The hairs and the hair cells of the organ of 
Corti exhibit no special change from the hair cells of the legenae. 

The histological proofs of these facts have been worked out 
by following the developmental series, beginning at the lowest 
mammals and noting the persistence of the hairs when no reagents 
were used, and their disappearance after the use of reagents. 
Professor Howard Ayer deserves the credit for establishing these 
facts. 

Conclusion. — These phylogenetic, ontogenetic, and histological 
investigations coincide to prove that the so-called tectorial membrane 
of the organ of Corti is an artifact of the long hairs of the neuro- 
epithelium of the organ of Corti, and that there is no structure which 
has a tone-selecting function. 

Will this theory of the undifferentiated sound-perception by 
means of the sensitive hairs fulfil the acoustic requirements? We 
find that it will, and better than any other theory and for the following 
reasons: Every property of a sound wave is shown in the charac- 
teristics of the wave front; these characteristics are variations in 
the curve of the wave, and we find that they are transmitted in 
every particular to the hair band. 

Every property of the sound wave is represented in the form of 
the wave. Every character of the wave form is imprinted upon the 
sensitive hairs of the neuro-epithelium of the organ of Corti. The 



464 



DISEASES OF THE NOSE, THROAT AND EAR. 



neuro-epithelium transforms the molecular sound vibrations into 
nerve impulses which are interpreted by the brain. 

The sound waves which enter the labyrinth from the middle 
ear in man, enter the perilymph, pass through the membranous 
walls of the scala media, and beat upon the long, delicate hairs of the 
organ of Corti, without any mechanism for the differentiation of 
special tones, just as they did on the maculae acusticae of the fish, 
or the sensory tufts of the lateral line organ. 







D 

Fig. 203. 

a, Curve of fundamental note; b, Curve of second Overtone in same phase; c, Result- 
ant curve, the regularity of which indicates harmony; d, The hairs of the organ of 
Corti acted upon by the resultant curve c. 

Each individual hair has a definite position for each instant of the wave, which 
position it occupies only once during the oscillation. It does not return to this position 
until it reaches the corresponding instant in a succeeding wave. 



The impulses received from the hairs of the organ of Corti are 
transmitted to the cochlear nerve endings, and the cochlear nerve 
carries the stimulation to the auditory center in the first and second 
convolutions of the temporal lobe of the brain. The hair cells 
transform the molecular sound motion into a nerve motion which 
the brain interprets. The accuracy of the analysis of the sound is 
proportionate to the education of the individual in the matter of tone 
perception. 

The cochlear nerve has extensive and important central and 



TONE PERCEPTION. 465 

cortical connections. It is chiefly connected with the higher centers 
in the cortex, but also has connections with the lower centers where 
it stimulates the reflex centers for appropriate automatic movements. 
The cortical connections of the cochlear nerve through the auditory 
sensory center are with the special centers whose complicated 
functions and intricate connections comprise the complex structure 
of the intellectual mechanism. The lower connections of the 
cochlear nerve are with the nuclei of the seventh cranial nerve and 
with the nuclei of the third, fourth, and sixth cranial nerves. These 
connections explain the reflex movements of the face and eyes 
associated with auditory stimulation. There are also connections, 
but less definite, with the motor tracts of the spinal cord and 
cerebellum and with the great sensory and motor tracts of the brain. 

TONE PERCEPTION. 

The perception of sound includes the perception of tone and noise. 

Tone. — The essential characteristic of tone is that it is composed 
of even impulses which recur with the regularity of a pendulum. 
The three properties of tone are intensity, pitch, and quality. 

Intensity is the term used to denote the relative amplitudes of the 
sound waves. 

Pitch is the term used to denote the relative rates of vibrations 
of different notes. Slow vibrations cause notes of low pitch, and 
rapid vibrations cause notes of high pitch. 

Quality is the term used to denote the different auditory effects 
of the same notes emanating from different sources. It depends 
upon the varying combinations and intensities of the accompanying 
overtones. 

The combination of two or more musical tones effect either 
harmony or discord. 

Harmony is the combination of tones having rates which are 
equal multiples of each other and which form an even resultant 
wave. 

Discord is produced when several notes are sounded whose rates 
are not whole multiples of each other. 

Tone Limits. — When regularly recurring waves or impulses occur 
slower than the rate of vibration of the lowest audible tone, the ear 
perceives them as distinct shocks. If the impulses increase in 
30 



466 DISEASES OF THE NOSE, THROAT AND EAR. 

rapidity, the intervals between the integral stimulation of the 
auditory nerve shorten until finally the irritation of the nerve becomes 
continuous. The lower tone limit is found at the instant when 
the ear perceives the lowest audible tone, which is about twenty- 
eight single vibrations per second. When the rate of vibration 
increases, the tone becomes higher and higher pitched until it is 
no longer perceived at the upper tone limit. The upper tone limit 
is about 100,000 single vibrations . per second. 




Fig. 204. — The Diagrammatic Curve of a Discord. 
a, Fundamental tone; b, A tone whose rate is one and one-half times more rapid than 
a. They start in the same phase, but soon irregularities and unevenness occur. These 
indicate discord, c, The resultant curve of a and b shows these irregularities. Beats 
are formed which recur with a rate one-half that of the fundamental a. 



Noise. — When the pulses or vibrations are irregular or uneven 
they are perceived as distinct shocks. When their rate of recurrence 
increases sufficiently for them to cause a continuous stimulation 
of the auditory nerve, they produce noise. A noise is usually 
composed of many vibrations of different wave lengths sounding 
simultaneously, like the rattling of a cart. 

Noises are probably perceived to some degree by all parts of 
the labyrinth. The perception of tone as such is confined to 
the cochlea, the papillaacustica, or organ of Corti, being the 
structure concerned in this sensory function. 

PHYSIOLOGY OF SOUND CONDUCTION. 

An important appendage to the labyrinth is made necessary 
for the continued perception of sound when the animal goes from the 
original denser aqueous medium into the rarer gaseous medium of 
the atmosphere. The conduction of sound waves from a rarer to a 



PHYSIOLOGY OF AIR CONDUCTION. 467 

denser medium encounters an almost insurmountable obstacle in 
this change of medium. This transmission is necessary because 
the sensory epithelium continues to be bathed in the dense endo- 
lymphatic fluid. This obstacle is surmounted by the development 
of the mechanism of the middle ear. This sound-transmitting 
mechanism is capable of collecting the diffuse sound waves of the 
rarer gaseous medium and focusing them sufficiently until their 
increased power allows them to pass into the labyrinthine fluids in 
the form of condensed waves of the denser medium. When once 
in the labyrinthine fluids the sound waves proceed as they did in 
the primitive labyrinth or canal organ found in the fish. 

PHYSIOLOGY OF AIR CONDUCTION. 

The mechanism for sound conduction focuses the wave impulses 
by the relatively smaller area of the inner end of the mechanism. 

Sonorous vibrations, transmitted through the air as sound waves, 
strike upon the concha, and are reflected against the tragus, which 
in turn reflects them into the external canal. The external canal 
directs these waves against the drum membrane. The drum 
membrane and ossicles are in a very delicate state of equilibrium 
called the acoustic balance, ready to respond to the most delicate 
impulse. This mechanism is set in vibration corresponding to the 
sound waves of the air which have penetrated to the bottom of the 
canal. The waves of sound which impinge on the membrane pass 
on through the handle of the hammer, through the chain of ossicles, 
and enter the perilymph from the foot-plate of the stapes. 

The sonorous vibrations are transmitted through the apparatus of 
the middle ear as a mass movement, as oscillations of the separate 
ossicles, or as a molecular movement. For tones of slow rate of 
vibration and of greater amplitude, the transmission is by means 
of mass or individual motion of the ossicles; for higher tones, tones 
of less intensity, the motion is molecular. In either case close 
apposition is required of the ossicles for perfect sound transmission. 
The drum membrane, the chain of ossicles, and the labyrinthine 
fluids vibrate as a single body of varying density through which the 
sound waves pass from end to end. 

A small amount of sound passes directly through the tympanic 
membrane and the enclosed air chamber of the tympanum, and 



468 DISEASES OF THE NOSE, THROAT AND EAR. 

impinges on the membrana tympani secundaria of the round window, 
the foot-plate of the stapes, and the outer wall of the labyrinth 
through which the waves, much reduced in intensity, pass to enter 
the labyrinthine fluid. The construction of this composite sound- 
conducting mechanism — composed of the concha, external canal, 
drum membrane, ossicles, perilymph and endolymph — is especially 
adapted to take up vibrations of the air over a large area and to 
transmit them to the perilymph over a small area. This mechanism 
receives a sound wave of lesser intensity and greater amplitude in 
a rarer medium, and transmits it as a wave of greater intensity and 
lesser amplitude in a denser medium. The force of the impulse 
transmitted to the perilymph from the air is increased thirty times, 
and the amplitude diminished seventy-six times or more. The 
apparatus for the conduction of sound begins in the concha and ends 
in the hair cells of Corti's organ. 

The physiology of the transmission of sound by the drum mem- 
brane depends upon the concavo-convex surface and the highly 
elastic structure of the drum membrane. The drum membrane is 
made of radiating and concentric fibers combined in such a manner 
as to render it extremely sensitive to sound vibrations. For the 
maintenance of this sensitiveness, it is necessary that the tension of 
the membrane should be in perfect equilibrium, and not weighted by 
unequal air pressure on either of its surfaces, or by unbalanced 
tension of the ossicles. 

In the erect position the center of gravity of the ossicles falls to 
the outer side of the axis of their motion, the weight of the drum 
membrane and its tension on the inner side of this axis, thus 
counterbalancing each other. The whole sound-conducting 
apparatus of the middle ear is constructed in such a way as to 
facilitate oscillation, but at the same time to prevent pendulum 
movements. The mechanism is easily moved from its position of 
rest, but on the return swing does not tend to pass beyond the center. 

Movements of the Ossicles. The hammer swings on an axis 
which passes through the processus gracilis in front. The incus 
swings on an axis which passes through its short process behind. 
These two axes meet in the incudomallear articulation. Both bones 
swing as one on this axis. When the handle of the hammer is drawn 
inward, the head of the hammer and the body of the incus, placed 
over the center of oscillation, are moved outward. If the drum 



PHYSIOLOGY OF AIR CONDUCTION. 469 

membrane moves outward, it carries with it the handle of the 
hammer, but owing to the form of the articular surface of the incus, 
the incus is moved very little and still less motion is transmitted to 
the stirrup, When the hammer handle swings inward, the long 
process of the anvil goes inward also, because the hammer and 
anvil lock, and the stirrup is pushed inward against the oval window. 
The contraction of the musculus tensor tympani, which draws 
the hammer handle inward, increases the tension of the drum 
membrane. The joint between the larger bones is locked and the 
anvil is moved inward; the long process swings inward, pushing 




Fig. 205. — Diagram Showing Acoustic Balance, and Axis of Motion of Ossicles. 
a, Atrium; d, Drum Membrane; e, Epitympanum; i, Incus; m, Malleus; s, Stapes; 
v, Vestibule. 



the stirrup ahead of it. Contraction of the musculus stapedius 
tilts the foot-plate of the stapes outward, and swings it on its lower 
posterior margin which is the fulcrum for all its movements. 

The ossicular chain, by holding the membrane tense, serves to 
maintain the acoustic balance of the drum membrane; and by 
increased tension or by relaxation, accommodates the membrane 
for the better reception of certain sounds. 

Combined contraction of both the tympanic muscles raises the low 
tone limit, lowers the upper limit of tone perception and decreases 
the duration of sound perception. 

Accommodation of the sound-conductinsr mechanism is brought 
about by the contraction of the tensor tympani muscle. This 
muscle is both accommodative and protective in its action, while 



470 DISEASES OF THE NOSE, THROAT AND EAR. 

the stapedius muscle is only protective. Contraction of the tensor 
tympani muscle increases the tension of the drum membrane and 
locks the articulation of the major ossicles, thus facilitating sound 
transmission, especially for vibrations of short wave length. Con- 
traction of the stapedius muscle pulls the stapes from the oval 
window and antagonizes sound transmission by weighting the stapes 
and at the same time holding it away from the oval window. 

The folds of mucous membrane in the cavum tympani and the 
bone trabecular and cells, serve to dampen the intratympanic 
air-borne sound waves, and thereby to prevent reverberation in the 
cavity. 

The function of the mastoid cells has nothing in common with the 
physiology of hearing; the cells serve only to lighten the bone struc- 
ture. The mastoid cells are most abundant when the bones are 
highly developed, as in a large muscular man. 

The physiological function of the tympanic pharyngeal tube is 
primarily to preserve the manometric balance of the drum cavity 
with the outside air. This is necessary in order that the drum 
membrane shall not be weighted on either side by air pressure and 
shall continue to possess the equilibrium necessary for the acoustic 
balance. The tube, while at rest, is barely closed at its pharyngeal 
orifice, so that the least pressure from within or without will force 
air through it. 

The tympano-pharyngeal tube differs from the ventilator of 
the military drum in the fact that it is closed most of the time, 
whereas in the military drum the aperture remains open. This 
closure of the pharyngeal tube is necessary for good hearing, because 
the condensation and rarefaction of the air in the naso-pharynx 
during expiration and inspiration would disturb the acoustic balance 
of the drum head and prevent its proper action. With an open 
tube, tinnitus is caused by movements of the drum membrane 
consequent on alternating condensation and rarefaction of the air 
in the tympanum. 

During the act of swallowing or gaping the contraction of the 
levator palati muscle pushes the angular process back of the alar 
cartilage of the tube. The cartilage swings backward, upward, 
and inward in the fossa of Rosenmiiller. At the same time the 
contraction of the tensor palati gives a rigid support to the anterior 
wall of the tube, while the motion of the alar cartilage draws the 



PHYSIOLOGY OF BONE CONDUCTION. 47 1 

posterior wall backward. The lips of the pharyngeal ostium 
separate at the lower commissure, forming a triangular orifice and 
obliterating the rugae of the tube. 

The secondary function of the tympano-pharyngeal tube is drain- 
age of the tympanic cavity. The ciliated epithelium of the tube 
accomplishes this tympanic drainage. The cilia of the tube receive 
the detritus of the natural metamorphoses of the lining membrane, 
or the products of inflammation which are delivered to it by the 
ciliated epithelium of the cavum, and waft them along the tube 
until they are discharged into the vault of the pharynx. 



PHYSIOLOGY OF BONE CONDUCTION. 

Besides being able to enter by the fenestra ovalis, the sound 
waves may pass through the tissues of the body and reach the 
labyrinthine fluid through the wall of the bony labyrinth. The 
sound transmission is much less perfect by this latter route and, 
on account of the mechanical disadvantages, it requires a much 
more intense aerial vibration to excite the auditory organ in this 
way. 



SOUND TRANSMISSION IN THE COCHLEA. 

The sound waves transmitted by the foot-plate of the stapes 
pass chiefly through the perilymph of the scala vestibuli, and 
through Reissner's membrane, to enter the scala media and strike 
against the hairs of the papilla acustica. Sound waves transmitted 
by bone conduction probably enter the perilymph of the scala 
tympani and vestibule and the endolymph of the scala media with 
equal intensity. The sound waves, which have entered the scala 
tympani may reach the organ of Corti through the basilar membrane 
and endolymph or through the helecotrema, Reissner's membrane 
and endolymph. The surplus energy of the sound waves entering 
by the stapes passes on through the helecotrema or through the 
basilar membrane into the scala tympani, and thence out through 
the membrana tympani secundaria, the latest development of the 
labyrinth. 



472 DISEASES OF THE NOSE, THROAT AND EAR. 

PHYSIOLOGY OF THE DETERMINATION OF THE 
DIRECTION OF SOUND. 

Mon-aural hearing receives waves of sound from all directions 
without any differentiation. It requires rotation of the head to 
locate the source of the sound. This movement serves to determine 
the direction from which the greatest intensity of sound proceeds. 
Mon-aural hearing, therefore, unaided, cannot determine direction 
of sound. Bin-aural hearing gives lateralization only, while it 
requires movement of the head — or of the ears, as in animals — to 
determine more definitely the direction of the sound. Movement 
of the sounding body serve to locate its position. Hearing is best 
at right angles to the axis of the concha. Consequently, the 
direction from which sounds are best heard by an individual ear 
depend upon the shape of the ear and upon the angle which the 
axis of the concha makes with the head. The direction from which 
the concha receives the greatest volume of sound waves is the 
direction of best hearing. 

The reason the mouth is opened in intense listening is to lessen 
the respiratory sounds and open the mouth of the external auditory 
canal by forward motion of the jaw. The increased tension on 
the anterior wall of the canal, due to the forward motion of the 
condyle of the jaw, causes increased tension of the drum membrane, 
which aids the sound-transmission in certain cases. 

The tactile sense of sound perception is present in all animals. 
The undifferentiated tactile sound perception exists also in man 
to a marked degree. The sense can be highly developed as shown 
in some blind deaf mute geniuses who can perceive and carry on 
conversation by the tactile sense alone. (This fact should be borne 
in mind when testing the labyrinthine sound perception of extremely 
deaf persons who may perceive sound by tactile sense and thus 
mislead the observer.) The tactile sense of vibration has practically 
no low limit; the normal high limit of tactile perception is between 
4,096 single vibrations and 8,192 single vibrations. 

PHYSIOLOGY OF EQUILIBRATION. 

The peripheral impressions which serve to maintain equilibrium 
and to coordinate movements are derived from the viscera, the 



PHYSIOLOGY OF EQUILIBRATION. 473 

skin, the muscles, the eyes, and — most important — from the vestib- 
ular apparatus of the labyrinth, which is the peripheral organ of 
equilibration. 

The peripheral organ of equilibration has several distinct functions 
which are divided between two distinct groups of organs, the vestib- 
ular system proper, and the semicircular canal system. These 
functions are: i. geotropic, 2. static, 3. cyclometric, 4. geometric. 

The mechanism of equilibration is a very complicated contrivance 
made up of peripheral and central portions. The central part of 
the mechanism is formed by the association of the sensory nerves 
from the peripheral portions of the mechanism in the lower centers 
of the central nervous system. Here these nerves are brought 
into communication with the motor center governing the muscular 
system, which is the dynamic portion of the mechanism. 

The peripheral space organ, the vestibule and its appendages, 
which are pressure organs, take cognizance of the direction of gravity 
and of movement in space. They depend, for their physiological 
action, upon their tactile perception of gravity, inertia, and friction. 
This physiological action is produced by the otoliths and endolymph. 
The specialized neuro-epithelium of the vestibule which lies on the 
maculae of the saccule and utricule, is provided with sensitive hairs 
upon which the otoliths rest in a mucoid substance. The stimula- 
tion of this epithelium is brought about by the attraction of gravita- 
tion, which draws the otoliths downward most forcibly against 
the lowest hairs. The sensations are interpreted by the sub- 
consciousness in the lower nerve centers as indicating the lowest 
and, by comparison, the highest parts of the vestibule. These data 
show the direction of gravity, which the higher centers interpret as 
up and down. All co-ordinated movements are performed accord- 
ingly. Should a movement of the body in a straight line be in- 
augurated, the inertia of the same otoliths will compel them to 
press most forcibly in the opposite direction to the motion. This 
stimulation is interpreted by the brain as indicating the inaugura- 
tion and direction of the motion. When the inertia of the otoliths 
has been wholly overcome, they cease to stimulate the sensory 
epithelium except by their weight. 

The otoliths, besides stimulating the geotropic sense of gravity, 
assist in the geometric sense of direction of motion, in the cyclometric 
sense of degrees of revolution, and in the static sense of commence- 



474 DISEASES OF THE NOSE, THROAT AXD EAR. 

ment and cessation of motion. Continued rotation can only be 
perceived through the intervention of the mechanism of the otoliths 
and their centrifugal action, since the mechanism of the semicircular 
canals ceases to act when the inertia of the endolymph has once been 
overcome. 

The sense of movements of the head on its axis depends upon the 
stimulation of the sensitive hair cells of the neuro-epithelium of 
the crista? in the ampullae of the semicircular canals. When there is 
a rotatory movement of the head, the inertia of the endolymph causes 
a slight backward current., which passes over the hair cells in the 
opposite direction to the rotation. This current is greatest in the 
canals whose planes lie most nearly in the plane of rotation. The 
inertia of the endolymph of the semicircular canals is soon overcome, 
the current ceases, and there is no further stimulation of the cristae. 
Sudden stopping of a rotatory motion causes the endolymphatic 
current to flow in the opposite direction and gives rise to a sensation 
of reversal of motion. 

The central connection of the vestibular nerve explains its im- 
portance in the equilibration mechanism. It is connected chiefly 
with the lower centers of the brain where are found sensory and 
dynamic centers of equilibration and coordination, which earn* 
out the complicated unconscious or reflex acts requisite for the 
maintenance of equilibration, muscular force and blood tension. 
The sensations of equilibration from the labyrinth are of such 
a nature that they are both positive and negative. This is accounted 
for by the balancing function of the peripheral space organs which 
take note of motions in all directions. 

PROTECTIVE MECHANISM. 

The external ear is a cushion and guard to the external auditory 
canal. The external canal is a protection to the parts within, since 
the curves of the canal render the passage of a straight object 
difficult. The cerumen secreted by the walls of the cartilaginous 
canal entangle particles of dust or small foreign bodies, or living 
creatures that may stray in, and holds them securely. The hairs 
at the entrance of the canal also serve to prevent the entrance of 
dust and insects, and to hinder the inflow of water. The outward 
growth of the horny layer of the canal carries with it any foreign 



PROTECTIVE MECHANISM. 475 

particles resting upon it, and the cerumen and foreign bodies which 
have become entangled in it, and deposits them outside. This 
movement of the epithelium tends to efface superficial scars. The 
growth commences in the cul-de-sac at the anterior-inferior part 
of the fundus of the canal and is directed upward, backward, and 
outward across the drum membrane. 

The protective mechanism of the middle ear is the ossicular 
chain. With its joints and muscles it is able to lessen the shock 
of too violent impulses from without, and to protect the delicate 
labyrinthine structures from concussion and overstimulation. 
The delicacy of the adjustment of the acoustic balance dampens 
gross movements and facilitates the transmission of minor move- 
ments. It also serves to protect the drum membrane from rupture 
and the attachment of the foot-plate from injury. These ends 
are accomplished by fixing the chain at both ends through the 
contraction of the intratympanic muscles. The protective contrac- 
tion of the muscles takes place involuntarily when the individual 
sees a flash of bright light, hears a loud noise, or anticipates or feels 
a shock, explosion or blow on the head. The contraction of the 
muscles draws the drum head in and renders it less liable to rupture 
from the expansion wave following the condensation wave of an 
explosion. The protective functions of the tube are the maintenance 
of equal air pressure on both sides of the membrane and the ejection 
of dangerous material from the tympanum. 

Anemia of the labyrinth from internal pressure is safe-guarded 
by a number of outlets for the perilymph and endolymph. The 
labyrinth has two aqueducts and two fenestra. The aqueducts and 
the internal auditory meatus connect directly with cranial lymph 
spaces ready to carry away any superabundant fluids. Sudden 
intralabyrinthine pressure is neutralized to a slight extent by 
the mobility of the membrana tympani secundaria of the round 
window and of the foot-plate of the stapes. Excess of pressure 
from the outside of the fenestra is warded off by the contraction 
of intratympanic muscles. Too low a tension in the labyrinthine 
fluid causes venous stasis which results in transudation of serum and 
restoration of the hydraulic balance. The required fluid may also 
be supplied by the inflow from the lymph spaces oi the central 
nervous system through the aqueducts. The normal intra- 
labyrinthine pressure is about the same as that of the cerebrospinal 



476 DISEASES OF THE NOSE, THROAT AND EAR. 

fluid which is one-tenth to one-seventeenth that of the carotids. 
The balance of tension of the endo- and perilymph is maintained by 
the elasticity of the delicate membranous wall of the endolym- 
phatic tube. The endolymph and perilymph are practically one 
fluid. 

Rapid changes of the tension of the labyrinthine fluid are also 
guarded against by the abundance of blood-vessels in the membranous 
labyrinth, chiefly in the stria vascularis. Under normal conditions 
the mechanisms are ample to correct any accidental change in the 
tension of the labyrinth and to protect the delicate neuro-epithelium. 
Pathological changes of both the blood-vessels and lymph channels 
may be expected before the tension is noticeably interfered with. 

The deep position of the hard, bony labyrinth serves for the 
protection of its extremely delicate structure. 

AUTHOR'S BIBLIOGRAPHY. 

Die Schnecke und ihre verallgemeinte Empfaenglichkeit fiir Toneindruecke. 

Archiv. f. Ohrenheilkunde, Leipsig, 1908, vol. lxxii, pp. 193-204. 
Die Lehre von den schallempnndiichen Haarzellen. Archiv. f. Ohrenheilk., 1909. 
Physiology of the Ear. Dr. C. H. Burnett's System of the Ear, Nose, and Throat. 

J. B. Lippincott, 1893, vol. i, part 1, pp. 83-92. 
The Piano-string Theory of the Basilar Membrane. Archives of Otology, 

New York, April, 1908, vol. xxxvii, No. 2, pp. 127-130. 



CHAPTER XXVII. 

PHYSIO-PATHOLOGY. DISTURBANCES OF THE AUDITORY FUNCTION. 

DISTURBANCES OF THE EQUILIBRATIONAL FUNCTION, MINOR 

DISTURBANCES OF FUNCTION. CENTRAL NERVOUS 

DISTURBANCES. 

GENERAL PATHOLOGY. FLORA AND FAUNA 
OF THE EAR. 

PHYSIO-PATHOLOGY. 

The functions of the ear show deterioration when any part of 
the ear is affected by disease. The most important of these func- 
tional losses are, diminished power of sound-perception and defects 
of equilibration. The less important losses are in the normal 
unconscious sensations derived from the ear which take cognizance 
of the pulse rhythm, of respiratory rhythm and sound, of vascular, 
intestinal, joint, lymph, and muscular sounds, and of minor sounds 
from surrounding objects. Through these unconscious perceptions 
we are able to take cognizance of the teeth, the intestines, the hands, 
the feet, the clothes, etc. When the hearing and the equilibrational 
senses are altered, these unconscious perceptions are also altered 
and the misinterpretations which follow have an injurious effect 
on the functions of the body. The results are reflected in altered 
processes, such as abnormal circulation, respiration, etc. 

DISTURBANCES OF THE AUDITORY FUNCTIONS. 

Deafness, when not due to defect in the nervous mechanism of 
hearing, is due to defect in the sound-conducting apparatus by 
which sound is lost on its passage from the outside air through 
the drum membrane, ossicular chain, peri- and endolymph, and 
sensory hairs of the organ of Corti, to the hair cells where the 
transformation to nerve motion takes place. Leaving out of 
consideration physical obstruction to the aerial passage of sound, 

477 



478 DISEASES OF THE NOSE, THROAT AND EAR. 

and the hindrance of sound transmission in the labyrinth, we come 
to the consideration of the mechanism for sound conveyance in 
the middle ear. The efficiency of this mechanism depends upon 
the delicacy of the acoustic balance. The acoustic balance is 
destroyed by any alteration, addition, or loss of tissue which disturbs 
either the vibratory power of the membrane or the mobility of the 
ossicles. Alterations of the elasticity of the drum membrane, 
increased or diminished tension, similar changes in the ossicular 
ligaments, or the absence of physiological action of the intra- 
tympanic muscles impede sound transmission and interfere with 
the perception of the highest and lowest tones. Increased tissue, 
due to congestion, hypertrophic thickening, inflammatory swelling, 
or accumulation of products of inflammation also interfere with 
sound transmission. Loss of tissue, whether it be a tiny hole in the 
membrana vibrans or a loss of membrane and ossicles, will also 
'cause an interference with sound transmission. The loss of tissue 
can be remedied, to some extent, by substitution of mechanical 
devices. A perforation in the drum-membrane may be closed by 
substituting for the lost vibrating surface a thin piece of sized paper 
or a small pledget of cotton, soaked in vaseline or water. These 
artificial drum membranes may also serve in case of relaxation 
of the membrane and ossicular ligaments, as weights and springs 
to hold the ossicles in apposition. In loss of all the ossicles or of 
the two major ossicles only, pledgets of cotton similarly prepared, 
will furnish resistance on the oval window, stapes, round window, 
and promontory which will improve the acoustic balance and greatly 
assist the hearing. 

The presence of an occluded Eustachian tube, irrespective of 
tympanic ventilation, inhibits hearing. The relief after blowing 
out a tube filled with secretions in cases of loss of tympanic membrane 
is very marked. 

Owing to the decussation of the cochlear nerve fibers and the 
operation of only one side of the brain for the auditory center, a 
sympathetic inhibition of the functions of the normal ear is brought 
about by a deaf ear. 

In advancing age diminution in hearing occurs in a constantly 
decreasing ratio. The loss begins before the thirtieth year and 
continues rapidly to the sixtieth or seventieth year, and then more 
slowly to the end of life. 



DISTURBANCES OF THE AUDITORY FUNCTIONS. 479 

The term aphasia is applied to the condition resulting from a 
loss in the speech mechanism. Sensory aphasia is the loss of 
the power to hear or feel words. Aphasia in its sensory form is 
due to some break in the nervous mechanism of the auditory center, 
or its association tracts and its associated cortical centers. The 
symptoms, which indicate impairment of some particular part, 
locate the lesion in that part. Amnesia, which is one form of 
aphasia, is the inability to remember the proper words. Psychical 
deafness alone is present when sounds are not heard, but when 
reflex acts, such as winking, follow auditory stimuli. Deaf mutism 
is applied to cases of deafness which have never perfectly developed 
the speech function. 

Tinnitus is a common accompaniment of pathological conditions, 
especially of impaired acoustic balance. Tinnitus is due to stimula- 
tion arising anywhere in the auditory tract, peripheral or central. 
This stimulation, when peripheral, is due either to a stimulation 
of the sensory epithelium of the cochlea caused by the reverberation 
of somatic sounds which would escape unheard through a normal 
middle ear or to very loud somatic sounds. The stimulation of 
the auditory tract may come from other forms of irritation, or may 
be reflex in nature. Snapping and cracking are due to the outward 
or inward motion of a relaxed drum head from manometric tympanic 
changes; these sounds may also be due to the opening of the pharyn- 
geal tubal mouth when the mucosa is sticky. 

In mentally unbalanced persons the tinnitus, because of the 
abnormal psychical conditions, gives rise to stimulation of the 
auditory centers which is misinterpreted to correspond with fixed 
ideas or hallucinations. In this way, tinnitus is the first cause, 
as well as the constant accompaniment, of auditory hallucinations 
in the insane. By its mental effect, or by the physical and mental 
exhaustion due to sleeplessness and the despair which it causes. 
tinnitus is sometimes the exciting cause of insanity. 

A drawing feeling in the ear is due to contraction of the tensor 
tympani muscle or to a negative air pressure in the tympanum. A full 
or heavy feeling is due to the presence of fluid in the tympanum, to 
over-distention of the drum-membrane, or to swelling of the tissues. 

Paracusis of Willis is a frequent symptom accompanying rigidity 
of the middle-ear sound-transmitting mechanism. With this 
symptom patients often hear better in a noise than in a quiet place. 



480 DISEASES OF THE NOSE, THROAT AND EAR. 

since the noise can move the rigid structures and allow the feebler 
voice sounds to pass in. 

Autophonia is the phenomenon which occurs when the middle- 
ear mechanism is obstructed, and is caused by the reverberation 
of sound reaching the middle ear by bone conduction. This symp- 
tom gives the strange hollow tone which the patient sometimes notes 
in his own voice, causing the voice to sound as if his head were in a 
barrel. The patient's foot-falls also sound strangely loud to him. 

Diplacusis, or double hearing, is due to difference in tension 
between the mechanism of the two ears. Pseudoacusis, false hearing, 
or diplacusis binauralis disharmonica, is due to the altered quality 
of tones heard in the two ears, giving these tones an apparent 
difference in pitch. Defect of acoustic balance is responsible for 
this symptom, which often causes great annoyance to musicians. 
Hyperacusis — abnormally acute hearing — and Dysacusis — abnor- 
mally painful sensitiveness to ordinary sounds — are phenomena 
due to weakened functional resistance of the nerve ganglion cells 
and centers, and to the painful emphasis of certain tones due 
to disturbance of the acoustic balance. After-impression sounds, 
that is, continuation of the sound sensation long after the sound has 
actually ceased, is also due to instability of the auditory ganglion 
cells. After-impression sounds — so-called after-impression tin- 
nitus—is similar in its pathological cause to after-impression visual 
images, and is due to overstimulation of the cochlear nerve or 
central mechanism. 



DISTURBANCES OF THE EQUILIBRATIONAL 
FUNCTIONS. 

Vertigo and dizziness are states of incoordination, resulting 
from overstimulation or unbalanced stimulation of the peripheral 
organ of equilibration, its central tracts, the muscular and cir- 
culatory systems, the visceral and tactile senses, and the eyes. 
Vertigo is a subjective sensation of motion of the body in space. 
The cause of the subjective sensation may be a positive or a 
negative stimulation of the vestibular apparatus. If the vertigo 
has a positive unilateral cause, the subjective motion is to the side 
of the affected vestibular apparatus. The patient in his attempt 
to correct his sense of loss of equilibrium and stem the tide of 



DISTURBANCES OF THE EQUILIBRATIONAL FUNCTIONS. 48 1 

objects which appears to move toward him from the side of the 
affected ear, falls on the affected side. He rarely tries to keep 
pace with the moving object, and consequently seldom falls on the 
healthy side. If the vertigo has a negative unilateral cause due to 
paralysis of one of the peripheral organs of equilibration, the 
subjective motion is toward the individual from the side of the 
healthy ear. The patient, by excessive attempts to retain equilib- 
rium, throws himself away from the affected ear and falls on the 
healthy side. If the dizziness does not cause the patient sensations 
of falling in any particular direction, it is due to an irritation of the 
whole vestibular organ. 

Nausea, vomiting, cold sweats, sea-green complexion, slow and 
weak pulse, and great muscular weakness, associated with vertigo, 
are consequent on the stimulation of the vagus nerve, through its 
close connection with the vestibular nerve. 

Nystagmus is due to overstimulation or unbalanced stimulation 
of the semicircular canals and vestibular apparatus, or of their 
tracts or centers in the brain, or to an irritation of the ocular part 
of the rotational equilibration mechanism. It is due to the sub- 
jective sensation of rotation, and is in the plane of and direction of 
this rotation. The rapid motion of the eyes when the nystagmus is 
due to irritation of otic origin, is toward the side of the affected 
ear; that is, in the direction opposite to the subjective motion of 
surrounding objects. With paresis or paralysis of one vestibular 
nerve, nystagmus, when present, is toward the healthy side; that is, 
in the opposite direction of the subjective motion of the surrounding 
objects. 

Seasickness is due to overstimulation of the vestibular nerve and 
occurs when the centripetal action of the otoliths is too powerful 
and when the change in the stimuli is repeated too frequently. 
The consequent exhaustion which results causes loss of equilibration 
and coordination and an associated stimulation of the pneumo- 
gastric nerve, with the consequent sensory, muscular, visceral, and 
circulatory phenomena. Individuals without a vestibular apparatus 
are not affected in this way. The immunity from the phenomenon 
of seasickness when the patient is flat on the back is due not so 
much to the elimination of the muscular, visceral and ocular 
vertiginous symptoms as to the location of the maculae acusticae 
or sensitive areas of the vestibule, which lie on the anterior wall of 
31 



482 DISEASES OF THE NOSE, THROAT AND EAR. 

the vestibule; therefore in this position the otoliths do not irritate 
the sensitve nerve epithelium, and no excessive stimulation results. 
The phenomena of seasickness resemble the sensations caused by 
a rotatory swing, except that in the sensations from the rotatory 
swing, the crista? acusticae receive the chief stimulation, whereas in 
seasickness the maculae acusticse are chiefly stimulated. In seasick- 
ness the motion is less violent, and a longer time is required to 
accomplish the reaction. 

MINOR DISTURBANCES. 

Pain or otalgia is due to inflammatory pressure on the sensory 
nerves of the ear, and is accompanied by local signs of inflammation. 
Reflex pain may originate in the ear and be referred to other organs, 
or it may originate elsewhere and be referred to the ear. The fifth, 
ninth, and tenth nerves are the ones usually implicated. The 
dental, pharyngeal, laryngeal, and nasal reflexes are the most 
common. When there is no congestion of the middle ear, the 
otalgia is always reflex. The reflexes are more often aurotropic 
than aurofugal. 

Itching is due to local irritation, congestion, dryness of the skin 
of the meatus, tickling of hairs in the meatus, to particles of cerumen, 
desquamated epithelium, or small foreign bodies. Internal itching 
may be due to mild irritation of the mucous membrane of the middle 
ear tract, especially at the mouth of this tube. Reflex itching, 
referred to the ear, originates usually in the nasopharynx. When 
the itching sensations originate in the ear, they are often referred to 
the nasopharynx or larynx, causing sneezing and coughing. 

CENTRAL NERVOUS DISTURBANCES. 

Epilepsy is sometimes dependent on aural diseases, epileptic 
seizures often following aural irritation in the predisposed. 

Aprosexia is a common result from persistent ear symptoms, 
such as pain, tinnitus, or the indescribable discomfort of ear disease. 
The patient, because of the persistence of the discomfort, is rendered 
incapable of mental application. 

Insanity. — Cortical irritation or toxemia from ear infections may 
go to the point of causing insanity in patients mentally unstable 



GENERAL PATHOLOGY. 483 

and with slight resistance. The form which the insanity takes 
is the toxic, depressant type. 

Diminished activity of the auditory tract is usually associated 
with arrest of mental development and loss of function, which is 
in proportion to the severity of the auditory symptoms. These 
mental disturbances are due partly to the aprosexia, consequent 
on the abnormal symptoms, and partly to the absence of concepts 
dependent upon lack of words to express mental processes. 

GENERAL PATHOLOGY. 

The general pathology of the ear has nothing peculiar to itself. 
The changes in the tissue, taken as a whole, are of the same character 
etiologically and pathologically as the changes in similar tissue in 
other parts of the body. 

The systemic diseases which often have ear complications are: 
influenza, measles, scarlet fever, pneumonia, epidemic cerebro- 
spinal meningitis, syphilis, diphtheria, tuberculosis, typhoid fever, 
diabetes, pernicious anemia, and leukemia. 

FLORA AND FAUNA OF THE EAR. 

Parasitic Flora. — A very large variety of bacteria are parasitic 
in the ear and are the cause of aural inflammation. A still larger 
number are occasionally parasitic under conditions of preexisting 
inflammation. There are also a certain number of parasitic moulds 
and aspergilli. Certain of the well-known pathogenic bacteria have 
a special predilection for the ear, where they show well-marked 
biological and pathological characteristics which influence clinical 
procedures and affect the prognosis of the otitis. Aural discharges 
usually contain two or three varieties of pathogenic bacteria and 
various saprophytic bacteria. 

The entrance of bacteria is favored by lowered vitality, by 
rickets, anemia, diabetes, nose and throat affections, inflammation 
of the external auditory canal, and wounds of the skin. 

Streptococcus encapsulates is the most virulent and the ihost 
fatal of the pyogenic micro-organisms. It has an almost irresistible 
power of extension, which involves the vital structures in the neighbor- 
hood of the middle ear. A biological and pathological characteristic 



484 DISEASES OF THE NOSE, THROAT AND EAR. 

of great importance is that its progress is often almost painless. 
While the infection spreads and the bone becomes completely 
disintegrated, the progress of the infection may cause only a mini- 
mum discharge of pus, a slight inflammatory reaction or swelling, 
and little or no change in temperature. 

Streptococcus pyogenes, the most common cause of ear infection, 
and the most virulent next to the streptococcus encapsulatus, is 
often present in gangrenous conditions and is a poor pus producer. 
Streptococci are characterized by unchecked advances in spite of 
surgical interference. 

In cases of streptococcus infection, the inflammation extends 
far in advance of the bacteria, and may cause necrosis and gangrene 
through coagulation necrosis, produced by the toxins, before pus is 
found. The necrosis may extend far ahead of the streptococci 
themselves. 

Streptococci predominate in severe cases of ear diseases and, 
although the most virulent of the micro-organisms, they soon lose 
their virulency. Complications of middle-ear infection show the 
same flora as the ear infections. It is noteworthy that the strep- 
tococcus is the commonest infection in complicated otitis. Sixty- 
six per cent, of the ear cases complicated with mastoiditis, meningitis, 
sinus thrombosis, perisinus abscess, epidural abscess, and brain 
abscess are due to streptococci. 

Streptococci are especially prevalent in sinus thrombosis, and 
in cases with general septicemia of aural origin in suspected sinus 
thrombosis, blood cultures should be made to aid the differential 
diagnosis, since streptococcemia is a pathognomonic symptom 
of thrombosis. The acute process runs a longer course with strep- 
tococci than with pneumococci, but, unlike the pneumococci, the 
streptococci do not remain latent after the acute stage before 
commencing complications. 

A very large proportion of infantile ear infections and their 
complications are due wholly or in part to pneumococci. Pneumo- 
cocci are rarely found in chronic middle-ear infections. 

Staphylococci occur in three forms — aureus, citreus, and albus. 
Staphylococci are the usual cause of otitis externa, and are commonly 
found in the canal. Staphylococcus albus is third in point of 
frequency and in degree of virulence in ear infection. It rarely 
occurs in pure cultures. Staphylococci are always found in otitis 



FLORA AND FAUNA OF THE EAR. 485 

media purulenta chronica. They are the most frequent cause of 
secondary infections consequent on otitis, and are, therefore, 
responsible for chronicity in ear suppuration. They occur in 33 
per cent, of the complications of ear suppuration, including mastoidi- 
tis, meningitis, sinus thrombosis, epidural abscess, perisinus abscess, 
intradural abscess, and brain abscess. 

Diplococci often cause epidural abscess, and are sometimes 
found in brain abscess. This organism may remain inactive for 
from two to six months. 

Other varieties of bacteria which may cause primary infection 
of the ear are: tubercle bacillus, diplococcus lanceolatus, pneumo- 
coccus (Friedlsender) , bacillus pyocyaneus (characterized by blue 
pus), bacillus coli communis, influenza bacillus, typhoid bacillus, 
streptococcus erysipelatis, bacterium lactis aerogenes, Neisser's 
gonococcus, bacillus mucosus ozaenae, Klebs-Loefner bacillus, 
bacillus pestis, micrococcus intracellularis meningitides, pseudo- 
diphtheria bacillus, anaerobic bacteria, bacillus mucosus capsulatus, 
and spirochaeta pallida. 

Otitis begins with only one bacterial excitant. A pure culture 
is less dangerous than a mixed infection. Middle-ear inflammation 
with mixed infection of several bacteria tends to become chronic, 
whereas cultures of a single variety of bacteria cause suppuration 
of short duration, or no suppuration at all. Asepsis should be 
rigorously employed in cases of acute suppuration or after operation, 
in order to avoid further bacterial contamination. 

Many middle-ear abscesses in childhood are sterile. Brain 
abscesses of long duration may be sterile. 

Since some of the bacteria may not grow on the culture media, 
a smear should always be taken in difficult and complicated cases 
of ear disease. A culture should be grown and an inoculation 
should be made in all cases of suspected tuberculosis in diphtheria. 

Complicating middle-ear inflammations occur in the following 
diseases: 

Two to 4 per cent, of cases of typhoid fever develop ear infections. 
usually in the fourth or fifth week. They are intercurrent affections. 
independent of the typhoid bacillus, and are caused by staphy- 
lococci, diplococci, or streptococci. Bacillus coli communis and 
typhoid bacillus have been found in mixed infection. 

With cerebrospinal meningitis, car disease is sometimes secondary 



486 DISEASES OP THE NOSE, THROAT AND EAR. 

to the brain disease. Micrococcus intracellularis meningitides 
proceeds along the auditory nerve from the brain membrane or 
through the aquaeductus cochleae et vestibuli to the inner ear. The 
middle-ear inflammation with the meningitis is usually a part of the 
general inflammation of the upper air tract and sinuses of the head. 

Two varieties of ear infection occur with influenza: i. Specific 
or early form, due to the influenza bacillus which gains entrance 
through the Eustachian tube and occasionally through the blood, 
and is found in the secretions of the middle ear. The ear infection 
begins on the first or second day of the influenza, and is characterized 
by hemorrhagic inflammation and the persistence of great pain in 
the ear in spite of drainage. 2. A secondary infection from the 
throat, with the usual bacteria of ear infection — diplococci, staphy- 
lococci, and streptococci. 

Streptococci are the most common finding in measles otitis. 
The otitic infection is usually due to the inflamed condition of the 
mucous membrane of the middle ear and to its diminished bacterial 
resistance. In about 60 per cent, of the cases of measles the middle 
ear is affected. The infection develops about the second week. 

Diphtheria otitis is caused by the Klebs-Loeffler bacillus. Pri- 
mary acute otitis media is rare. A secondary middle-ear infection 
which accompanies the diphtheria is the most common form. 
The ear infection may yield a pure culture at first, but the infection 
soon becomes mixed. Diphtheria otitis of scarlet fever is a 
secondary infection on the preexisting scarlet fever otitis. 

Scarlet fever otitis is of two forms — the early destructive form 
and the later milder form. In severe scarlatinal infections, strep- 
tococci are found in the blood, either free or enclosed in the leukocytes. 
These micro-organisms are also in the stroma of the mucous mem- 
brane, and sometimes in the lymph cells of the connective tissues. 
Both these organisms and their toxins cause ear suppuration and 
rapid destruction of the soft tissues and bone. In these cases, the 
streptococcic otitis is a symptom of general streptococcic infec- 
tion. Pseudodiphtheria bacilli are sometimes the cause of ear 
inflammation. 

Tuberculous otitis is very often the first sign of a commencing 
lung tuberculosis. The ear may be infected in the course of a 
general tuberculosis or may be the primary seat of the infection. 

Syphilitic otitis is occasionally consequent on a primary lesion 



FLORA AND FAUNA OF THE EAR. 



of the outer parts or it may be a secondary or tertiary manifestation 
of the general disease. 

In cases of severe aural infection serum treatment has been 
tried with a few of the common organisms, notably with strepto- 
cocci. The results thus far have been unsatisfactory, because the 
cases tried were extremely urgent and could not brook the delay 
necessary for the preparation of the individual serum. The sera 
kept in stock are usually inefficient in an individual case. 

Aspergilli. — The aspergilli are found in the external canal. 
They are only accidentally parasitic. Their growth may be 





Fig. 206. — Characteristic Appearance of A pergilli, showing Spores and Fibers 

(magnified). 



saprophytic for some time before they penetrate the epithelium 
of the canal and become parasitic. After they have started their 
pathic course, they may go deeply and even penetrate, by ulceration, 
into the drum, where they may open the way for the entrance of 
more virulent organisms. Varieties of the aspergillus are the black, 
yellow, and white forms. 

The saprophytic flora of the ear comprises a very large variety of 
non-pathogenic bacteria, the most important of which are putre- 
factive bacteria. The smegma bacillus is sometimes found in the 
ear, and may be mistaken for the tubercle bacillus. There is also 
a large variety of moulds of little importance found in the external 
meatus. The moulds arc seen growing on collections of cerumen 
or inspissated discharge and epithelium. Blastomycetes and 
actinomycoses are sometimes found in the ear. 



488 DISEASES OF THE NOSE, THROAT AND EAR. 

FAUNA OF THE EAR. 

The fauna of the ear comprises visitants from among the various 
species of insects whose habitat is identical with that of man. 
These insects have sufficient strength to pass the hair barrier and 
are not too large to enter the canal. The forms most commonly 
found are: diptera, hymenoptera, lepidoptera, coleoptera, and 
pediculi. The only true animal parasites of the ear are diptera 
larvae (maggots). They are the larvae of the common carnivorous 
and house fly, which thrive in the environment of a suppurating 
ear. 

AUTHOR'S BIBLIOGRAPHY. 

The Great Psychical Importance of Ear Disease. Journal of Nervous and 

Mental Disease, New York, Sept., 1906, vol. xxxiii, No. 9, pp. 553-562. 
Aural Affections in Relation to Mental Disturbances. New York Medical 

Journal, March 23, 1907, vol. lxxxv, No. 12, pp. 549-551. 
Functional Derangement of the Ears and Upper Air Tract in the Insane. 

Medical Record, N. Y., August 25, 1906, vol. lxx, No. 8, pp. 281-283. 
Report of a Possible Case of Intracranial Arteriovenous Aneurysm or Exoph- 
thalmic Goiter. Am. Jour. Surgery, N. Y, July, 1906, vol. xx, No. 7, 

pp. 213-214. 
A Case of Profound Streptococcus Infection of Aural Origin, treated by Operation 

and Vaccination with Antistreptococcic Serum, followed by Death from 

Meningitis. Annals of Otol., Rhin. and Laryn., St. Louis, 1907, vol. 

xvi, p. 689. 
A Case of Streptococcus Encapsulatus Aural Infection and Modified Radical 

Mastoid Operation. Archiv. of Otology, N. Y., vol. xxxvii, 1908, p. 69. 
Tinnitus Aurium and Hallucinations of Hearing; or the Relation of Ear Disease 

to the Auditory Hallucinations of the Insane. The Laryngoscope, St. 

Louis, Oct., 1905, vol. xv, No. 10, p. 802. 
A Case of Carcinoma of the Middle Ear, probably Endothelioma. Annals of 

Otology, Rhin. and Laryn., St. Louis, June, 1907, vol. xvi, No. 2, p. 301. 
Tuberculosis of the Ear. New York Medical Record, Sept. 26, 1908, vol. lxxiv, 

No. 13, pp. 513-516. 
De la Grande Importance Psychique des Affections d'Oreilles. Archiv. Internat. 

de Laryn. d'Otol. et de Rhin., Paris, Jan. Feb., 1907, vol. xxiii, No. 1, 

PP- 8 5-95- 
Tinnitus Aurium, Hallucinations of Hearing, or the Relation of Ear Diseases 
to Auditory Hallucinations of the Insane. Annals of Otol., Rhin. and 
Laryn., St. Louis, vol. xiv, 1905, pp. 547~553- 



CHAPTER XXVIII. 

ETIOLOGY OF EAR AFFECTIONS. ETIOLOGY OF PRIMARY EAR DISEASES. 

ETIOLOGY OF SECONDARY AFFECTIONS OF THE EAR! I. FROM 

PATHOLOGICAL CONDITIONS OF CONTIGUOUS STRUCTURES*, 

2. FROM SYSTEMIC CAUSES. DRUGS THAT MAY 

CAUSE EAR DISEASES. HEREDITY AND AGE. 

PREVENTION OF EAR DISEASE. 

ETIOLOGY OF EAR AFFECTIONS. 

Etiology of Primary Ear Diseases. — The number of ear diseases 
with causes originating in the ear itself is comparatively small. 
The great majority of cases which at first appear to be primary 
are, when carefully studied, clearly seen to be secondary to some 
constitutional disease or to the effect of changes in structures 
contiguous to the ear, especially in the nasopharynx. In the 
category of primary ear diseases we have: i. local interference 
with physiological functions; 2. neoplasms; 3. local and idiopathic 
infections; 4. trophic disturbances; 5. local injuries; 6. diseases 
caused by foreign bodies, and 7. diseases caused by certain 
occupations. 

Primary ear disease may be dependent upon abnormally crooked 
or narrow external auditory canals, which interfere with the evacua- 
tions of normal secretions, detritus, etc. This condition of the canals 
favors the occurrence of eczema, accumulations of cerumen, and 
keratosis. The slightest occlusion of the canal may cause important 
middle- and inner-ear complications. 

Neoplasms, when they have their origin in the ear structures, 
are etiological factors in the production of primary ear disease. 
Otic tumors include epitheliomata, carcinomata, sarcomata, 
endotheliomata, granulomata, myxomata, fibromata, keloid, se- 
baceous cysts, cholesteatomata, gummata, adenomata, papillomata, 
angiomata, chondromata, lipomata, aneurysms, neuromata, and 
branchial cystomata. These growths may be due to retention of 
secretion, to irritation, or to traumatism. Tumors due to mention 

489 



490 DISEASES OF THE NOSE, THROAT AND EAR. 

are cholesteatomata, sebaceous cystomata, and branchial cystomata. 
Tumors due to irritation, are myxomata, granulomata, fibromata, 
osteomata, and epitheliomata, the irritant usually being an acrid 
discharge from the ear. New growths due to traumatism are 
fibromata, keloids, and hematomata. 

Idiopathic infections, as etiological factors of primary ear disease, 
are rare, since most primary infections of the ear are dependent on 
traumatism. The external ear is most subject to primary infection, 
erysipelas, tuberculosis, syphilis, eczema, and other skin affections. 
The middle ear may sometimes contain pyogenic bacteria, which 
may invade the tissues at times of lowered constitutional resistance. 

Trophic disturbances may affect the cerumen and epithelium 
of the auditory canal, causing disease of the external ear. The 
same causes may affect the Eustachian tube and impede its functions, 
thus affecting the middle and inner ear. Trophic disturbances may 
also affect the middle ear and later involve the labyrinth. 

EAR DISEASES CAUSED BY LOCAL INJURIES. 

Wounds — punctured, incised, contused — and bites cause ear 
disease, through infection and resulting deformities. 

All accidents, with loss of continuity, besides the immediate 
harm and injury to the hearing mechanism, may open the way 
for infection. 

Boring the ears for earrings often causes keloid, especially among 
the African race. Falls may cause fracture of the temporal bone, 
associated with fracture of the base of the skull, and consequent 
injury to the ear. Falls, blows on the ears, explosions and very 
loud sounds may cause rupture of the drum membrane and injury 
to the organ of Corti, either from the compression or expansion wave 
which follows. In the case of explosions, the rupture is generally 
caused by the expansion wave, and occurs in the posterior half of 
the membrane; whereas with blows on the ear, the rupture is due 
to compression and usually occurs in the anterior naif of the mem- 
brane. Accidents may befall the nervous mechanism of the cochlear 
nerve from the blast of small guns and small explosions, from 
long-continued musket-fire, from rapid-firing machine guns, 
impact from steam whistles, loud voices, and other intense 
sounds. 



EAR DISEASES CAUSED BY LOCAL INJURIES. 49I 

Extremes of cold and heat are sometimes factors in causing ear 
disease. Frost-bites produce inflammation of the external ear. 
Chilling of the middle ear may be the exciting cause of injection 
and inflammation. Burns and scalds are more liable to injure the 
exposed surface of the pinna than the inner parts of the ear, which, 
because of their deep position, are rarely affected. 

Faulty personal hygiene of the ears, such as scratching or picking 
the ear with finger-nail, hatpin, hairpin, toothpick, match, pin, 
pencil, or towel, is a frequent cause of infection of the canal, otitis 
externa, and dry eczema. Snuffing instead of blowing the nose, 
and swallowing with obstructed nostrils, by aspiration of the air in 
the tympanum, are causes of diminished intratympanic pressure and 
consequent injury to the acoustic balance. Too forcible or too 
frequent inflation of the middle ear is a usual cause of relaxed 
tympanic membranes, a serious obstacle to hearing. Too hard 
blowing of the nose may cause the same relaxation. Too forcible 
or too frequently repeated pneumatic massage may also cause 
relaxation of the drum membrane and of the ossicular ligaments, 
with loss of acoustic balance. Too frequently repeated sound 
massage is sometimes the exciting cause of boiler-makers' disease 
and of nerve impairment. 

Improper handling of the ear by its possessor or by others, including 
mistaken acts of ear toilet or of hydropathic and physical thera- 
peutics, is a frequent cause of primary ear disease. 

The use of fluids in the nasopharynx for therapeutic purposes, 
especially the use of nasal and postnasal douches, often results in 
the blowing, aspiration, or syringing of the fluid from the naso- 
pharynx into the tympanum, thereby clogging the mechanism and 
causing infection. Snuffing fluids up the nose through aspiration 
or subsequent blowing drives the fluid with bacteria into the middle 
ear and causes infection. 

Bathing is often accompanied by the clogging of the nasopharynx 
with water and mucus. In the effort to remove these fluids by 
blowing the nose or by sniffing, water or infected mucus may be 
drawn into the middle ear through the tympano-pharyngeal tube 
where they often excite infection and inflammation. Water and 
sand may enter the fundus of the canal during bathing and act 
as irritating foreign bodies and as excitants oi infection. The 
continued presence of water in the canal is the usual cause ol 



49 2 DISEASES OF THE NOSE, THROAT AND EAR. 

osteomata and hyperostoses of this region. Deep diving, owing to 
compression of the tympanum, may cause considerable injury to the 
sound-conducting structures. 

Improper violence in the removal of foreign bodies is often followed 
by injury to the canal and tympanum. Unskillful use of instruments 
in the canal and middle ear rapidly causes injury and disastrous 
consequences. Results are laceration and contusion of the external 
parts, with possible infection, rupture or puncture of the drum 
membrane, and sometimes dislocation of the ossicles. 

Foreign bodies, which are the most frequent cause of primary 
ear diseases, are usually put in the ear by the patients themselves, 
though occasionally by others; insects may sometimes crawl into 
the ear. Foreign bodies give rise to disease by irritation and by 
obstruction of the canal and tympanum. 

There are certain occupations which, by continually exposing the 
ear to an abnormal environment, are potential causes of injuries 
to the ear. Boiler-makers and men employed in gunneries often 
have ear trouble because of their noisy employment. Swimming, 
which exposes the ear to too much water, and diving and caisson 
work which expose the ear to too much or to too little pneumatic 
pressure, are among the occupations likely to affect the organ. 

Etiology of Secondary Ear Affections Which Arise from Pathological 
Conditions Near the Ear. — The pathological processes of the upper 
air tract affect the ear directly by extension along the mucous mem- 
brane, and indirectly by extension through lymphatics and blood- 
vessels, or by mechanical interference with the function of the 
Eustachian tubes. Much injury may befall the ear through vaso- 
motor disturbances affecting its blood supply arising in the naso- 
pharynx. Partial or complete obstruction of the nose or pharynx 
and inflammation of the nasal mucosa and of the nasopharynx, 
coryza, tonsillitis, hay fever, etc., cause closure of the tubes and circu- 
latory disturbances of the ear predisposing to ear infection. The 
nasopharynx through the influence of blocked Eustachian tubes 
with impeded drainage and ventilation of the drums furnishes the 
predisposing cause of between 80 and 90 per cent, of all ear diseases. 
The nasopharynx also affects the ear unfavorably through circula- 
tory disturbances, both direct and reflex. 

Skin affections of the face often affect the ear by extension; these 
are erysipelas, eczema, epithelioma, syphilitic erosions, and lupus. 



EAR DISEASES CAUSED BY LOCAL INJURIES. 493 

Occasionally affections of the cerebrospinal system invade the ear 
by direct extension from within, especially in epidemic cerebrospinal 
meningitis. The auditory nerve and roots are sometimes affected 
by the extension of lesions from the contiguous parts of the brain, 
in tabes, general paresis, and multiple sclerosis. New growths 
may extend to the auditory nerve and roots. Pathological conditions 
of surrounding structures sometimes affect the ear unfavorably; 
among these affections are hypertrophy of the faucial and pharyngeal 
tonsils, parotitis, lymphadenitis, aneurysms, and new growths. 

Reflex, trophic, and circulatory ear disturbances may arise from 
irritation of the pharynx, nose, or teeth. The circulatory changes 
take place first, and the trophic changes are consequent. Neuralgia 
or sensory reflexes are very common, especially from the teeth. Irrita- 
tion of the fifth nerve from carious teeth, gingivitis, from abnormal 
eruption of the teeth, from ill-fitting plates, and other dental appli- 
ances, nasal irritation and irritation of the ninth and tenth nerves 
from disturbances of the tonsils, pharynx, and larynx, also affect the 
circulation of the ear reflexly, and sometimes cause reflex otalgia 
and inflammation. Intranasal pressure and inflammation may 
cause the same symptoms. Reflexes from the glossopharyngeal 
and pneumogastric nerve sometimes cause similar ear reflexes, 
originating from pharyngeal and laryngeal irritations. 

The etiology of secondary ear disease from systemic causes includes 
the general systemic diseases, circulatory changes, blood diseases, 
and diseases of the nerves. General systemic diseases which have 
a bearing on the ear are infectious diseases, such as measles, 
scarlet fever, diphtheria, epidemic cerebrospinal meningitis, variola, 
mumps, influenza, phthisis, syphilis, typhus, typhoid fever, malaria, 
and lobar pneumonia. Other general diseases and conditions 
causative of secondary ear disease are general trophic condi- 
tions of malnutrition, cachexias, Bright's disease, diabetes, and 
leucocythemia. 

The systemic diseases affect the ear through lowered functional 
activity and decreased vitality and by lessened local and general 
resistance to infectious processes which are a part or a complication 
of the original disease. The first step in the process of ear involve- 
ment is the alteration of the nasopharyngeal mucosa which renders 
it more liable to infection, and the infection is, therefore, more 
liable to spread to the ear. Hearing is diminished in febrile diseases 



494 DISEASES OF THE NOSE, THROAT AND EAR. 

associated with marked nervous and muscular impairment, as well 
as in anemia, gouty conditions, and digestive disturbances. 

General circulatory disturbances which cause ear diseases do 
so through local anemia, hyperemia, toxemia, bacteriemia, and 
diseases of the vessel walls. If these conditions are prolonged 
they cause degenerative ear changes. Hyperemia, if active, causes 
hypertrophic changes which later result in atrophy. If the hyper- 
emia is passive, resistance of the mucous membrane to infection 
is diminished. Toxemia has a destructive effect, especially on 
the nervous tissue of the ear. Bacteriemia may cause metastatic 
inflammations of the ear. Diseases of the vessel walls may lead to 
hemorrhage in any part of the auditory tract, with very considerable 
injury to the organ. 

Diseases of the nervous system cause ear disease through inter- 
ference with the nervous system of the ear which causes trophic 
motor and functional changes. Nervous exhaustion affects the 
ear before any other sensory organ. Tabes, locomotor ataxia, 
general paresis, hysteria, neurasthenia, and insanity affect the ear 
through mental impairment and nervous exhaustion. 

Drugs that may cause ear disease. The most important of these 
drugs is quinine, which causes degeneration of the peripheral 
cochlear nerve mechanisms. The salicylates, the next commonest 
of the drugs which cause ear disease produce changes similar to the 
effects of quinine. Iodides, and less frequently, aconite, sometimes 
cause ear diseases by inducing inflammation of the pharyngeal 
and tympanic mucous membrane. Other drugs that have a 
deleterious effect on the ears through nervous disturbances of the 
auditory tract, centers, and peripheral mechanisms, are salol, 
morphine, chloroform, alcohol, and tobacco. 

Heredity plays an important role in some forms of ear diseases, 
chiefly in the suppurative inflammations of childhood, and in the 
non-suppurative inflammations of later life. These pathological con- 
ditions are in no sense congenital, but the conditions and tendencies 
which give rise to them are inheritances, namely, the predisposition 
to adenoids in childhood and the constitutional nervous impairments 
of later life which affect the ear unfavorably. Ear malformations 
are congenital and often show an hereditary tendency — appearing 
and reappearing in succeeding generations. With advancing age, 
hearing decreases in a normally constantly increasing ratio. 



EAR DISEASES CAUSED BY LOCAL INJURIES. 495 

The prevention of ear disease requires the successful management 
of the etiological factors. The majority of the causes of ear disease 
can be controlled by the physician, especially the most common 
cause, which is deranged function of the tympano-pharyngeal tubes 
due to disturbances in the nasopharynx. 

The preservation of hearing depends upon the maintenance of 
the ear in its normal condition, and the prevention of further loss 
of hearing in damaged ears. In order that our care of the ear may 
be effective, it is necessary that the ear should be tested or examined 
from time to time — every year or so. In this way defects that have 
arisen may be detected and remedied before they cause any consider- 
able damage. Care of the ear, from the patient's point of view, 
should be a periodic examination by the specialist; in the inter- 
vals, leave the ear intact and avoid conditions that will affect the 
general health unfavorably; especially important is the avoid- 
ance of nasopharyngeal disorders that reach the ear through the 
Eustachian tube. 

AUTHOR'S BIBLIOGRAPHY. 

Die Rosenmuellersche Grube als aetiologischer Faktor der Mittelohrenzuen- 
dung. Archiv. f. Ohrenheilkunde, Festschrift, Leipzig, 1907, vol. lxxiv, 
p. 40. 

Chronic Middle Ear Deafness. N. Y. State Journal of Medicine, 1908, vol. viii, 
p. 34i. 

The Preservation of Hearing. Medical Record, N. Y., March, 1907, vol. lxxi, 
No. 9, pp. 349-35°- 

Tinnitus Aurium: Etiology. Annals of Otology, Rhinology, and Laryngology, 
St. Louis, March, 1904, vol. xiii, No. 1, pp. 111-120. 

Deaf-mutism and Ptomaine Poisoning. Medical Record, N. Y., vol. lxvii, 1905, 
p. 292. 

Pathology and Prognosis of Chronic Progressive Hardness of Hearing; Otoscle- 
rosis. Annals of Otology, Rhinology and Laryngology, vol. xvii, No. 
3, pp. 652-660. 



CHAPTER XXIX. 

EXAMINATION OF PATIENTS. DIAGNOSIS OF EAR DISEASES. 

A careful record of the examination of each patient should be 
kept in order to furnish a reliable basis upon which to estimate 
changes in the condition of the patient, and as a means of determin- 
ing whether to continue or to alter the treatment. 

History. — The personal history of the patient should be taken, 
and the data should include, besides the history of the present ear 
attack, the history of all previous attacks. The history should also 
include a record of all conditions which may have a bearing upon the 
present state of the ear, systemic diseases, cutaneous diseases, nervous 
conditions, nasopharyngeal conditions, social conditions, personal 
hygiene, worry, drug and moral habits, and so forth. The family 
history for hereditary deafness and for constitutional conditions 
should be recorded. 

Inspection of Auricle. — The skin of the auricle and surrounding 
region should be inspected, and both sides compared. The presence 
of any superficial lesions, tumors, or deformities can readily be seen. 
The auricle and skin should be palpated to locate tenderness, and 
traction should be made on the auricle for the same purpose. 
Tenderness which is most marked when the tragus is pressed, indi- 
cates otitis externa. The presence of swelling adjacent to the auricle 
should receive especially careful investigation. Anterior swelling 
suggests otitis externa. If the tenderness is found to be increased 
toward the meatus and is absent at a short distance from it, otitis 
externa is probable. 

Posterior swelling suggests mastoiditis. If the tenderness is 
behind the ear and is increased by deep pressure on the bone, 
rather than on the cartilage of the meatus, the indications are that 
periostitis exists, probably accompanying mastoiditis. Points where 
deep or superficial pressure locate tenderness should be noted. In 
cases where the differential diagnosis between otitis externa and 
mastoiditis is difficult, great care must be exercised when the pressure 
is made on the bone, in order to avoid any pressure or reaction on 

496 



EXAMINATION OF PATIENTS. 



497 



the canal. There are .three points of tenderness behind the ear 
to be considered: tenderness of the tip of the mastoid process, 
tenderness of the mastoid antrum — that is, directly back of the meatus 
— and tenderness at the posterior end of the digastric fossa and 
emissary veins — that is, behind the base of the mastoid process. 
These signs of tenderness are given in the order of frequency and in 
the inverse order of their importance. 

Inspection of the cartilaginous portion of the canal is made to detect 
superficial lesions, presence of discharge, foreign bodies, tumors, 
or deformities. The general character of the caliber of the canal 
should be noted. Any considerable swelling or the presence of any 




Fig. 207. — Diagram showing the forehead mirror worn on the observer's left eye, the 
direction and angle of the light, and the line of vision. The method of holding the fine 
angle applicator while fixing the depth of the ear. 

foreign substance is readily observed. The character of the 
discharge should be noted. Circumscribed otitis externa is shown 
by the presence of furuncles or by localized swelling and tenderness 
in the cartilaginous meatus. Pressure with a probe will indicate 
the location of the boil by the sharp tenderness. 

Examination of the osseous part of the canal requires the use of a 
forehead mirror, reflected light, and an aural speculum. The 
mirror should be worn as seen in the diagram (Fig. 207V over the 
left eye, on right-handed persons; the left eye should be used tor 
looking through the aperture of the mirror for the subsequent 
examination. The light should be sufficiently strong to cause a 
distinct shadow. The position of the light, relative to the mirror 
32 



498 



DISEASES OF THE NOSE, THROAT AND EAR. 



and to the ear, is important. The ear to be examined should be 
toward the observer, and the light beyond the patient. The light 
should be placed in such a position that it will come to the mirror 
as nearly parallel to the light going from the mirror to the ear as 
possible. The light should shine on the mirror just over the patient's 
head, to the left of the observer. The observer should tilt the 
mirror so that the full strength of the reflected light falls on the 
meatus. He should then adjust the angle of the mirror without 
moving his head or allowing the light to leave the meatus, so that 
he can see the meatus with his left eye through the opening in the 




Fig. 208. — Inserting speculum in right ear. The speculum is held between the index- 
finger and thumb of the observer's left hand and rolled into the canal, while the pinna 
is grasped between the middle and ring-fingers and pulled upward and backward. 



mirror. The fine structure of the tympanum cannot be seen at long 
range, therefore the eye of the observer should be as near the ear as 
working room will allow. If the hypermetropia of the operator will 
not allow this, he should wear in the aperture of the mirror a lens 
of sufficient convexity to allow him to see at close range. 

The speculum should be held between the thumb and index- 
finger of the left hand, and inserted with caution, rolling it between 
the finger and thumb to avoid pain and injury to the patient. 
While inserting the speculum the right ear of the patient is grasped 
between the middle and the ring-fingers of the observer's left hand, 
and pulled upward and backward at the same time that the speculum 
is inserted with the forefinger and thumb. In the case of infants 



EXAMINATION OF PATIENTS. 



499 



the auricle is pulled downward. When examining the left ear, 
the speculum is inserted in the same way, but the auricle is pushed 
upward and backward by the pressure of the tip of the middle 
finger inserted in the upper part of the concha. The observer 
should insert the largest speculum which the size of the cartilaginous 
meatus will allow. It is less likely to cause discomfort to the patient 
and will afford a larger field of observation for the observer. 

Since the examination must be done with one eye alone, the 
appreciation of perspective is difficult. In order to get the proper 
perspective, it is well, when an object is in view, to move the eye 




Fig. 209. — Inserting speculum in the left ear. The speculum is held between the thumb 
and forefinger of the left hand of the observer and rolled into the cavity, while the tip 
of the middle finger forces the concha up and back. 

very slightly. This will afford a different angle of vision, and will 
show differences Of distance that exist between objects on the line 
of vision. 

The osseous meatus is examined for discharge, congestion, 
crusts, cerumen, epithelial masses, exostoses, polypi, and other 
growths, fistulae, narrowing and swelling of the walls, and foreign 
bodies. Swelling of the walls indicates periostitis. When located 
at the inner end of the upper posterior part of the canal, the swelling 
is an indication of osteitis of the anterior mastoid wall and is. 
therefore, a sign of mastoiditis. The character of the discharge 
is an important indication of the changes in the middle ear. Very 
acute inflammations are characterized by serum and blood; chronic 



500 DISEASES OF THE NOSE, THROAT AND EAR. 

inflammation, by pus. The odor of the discharge indicates the 
presence or absence of decomposition, necrosis, and of various 
infections. Mucus in the discharge indicates perforation into the 
middle ear. 

Examination of the drum membrane must be done systematically 
so that no detail may be overlooked. In order to be sure that 
the entire membrane is inspected, follow with the eye the posterior 
wall of the canal inward and across the drum membrane forward, 
observing the umbo and the light reflex, and continue forward to 
the anterior canal wall. Then follow the upper canal wall inward 
to the drum membrane. Observe Shrapnell's membrane, the short 
process of the hammer, the posterior fold of the membrane, and 
the posterior superior quadrant of the membrane. Looking down- 
ward along the hammer handle, observe the angle at which it hangs, 
then to the umbo, and finally downward to the inferior wall of the 
canal. 

Drum Membrane. — The mental picture of the normal drum 
membrane should be taken as the basis of comparison. Any 
deviations from the normal are to be noted. These deviations may 
be classified under color, texture, position, surface, and continuity. 

The color of the normal drum membrane is a pale pearly-gray. 
Various color changes, to pink, scarlet, dark-red, are noted in 
different congested conditions.. Inflammatory changes are shown 
by a pinkish flush, darkened, in advanced conditions, into deep red. 
The congestion first shows itself by red lines along the hammer 
handle, and along the periphery of the membrane and meatal wall. 
The color of the promontory may be seen through a normal or thin 
membrane, appearing slightly yellow close behind the umbo. If 
the promontory is congested, the yellow color changes to a faint 
pink or bluish-red tint. Posterior to the promontory a darker 
area indicates the round pelvis. A lighter-colored line close to, and 
parallel to, the upper half of the handle, indicates the long process 
of the incus, with the stapes at its tip, resting in the oval pelvis. 
The tympanic membrane sometimes appears to have a bluish 
tinge, which is indicative of blood in the tympanic cavity. A 
yellowish tinge is often imparted to the membrane by the presence 
of pus in the tympanic cavity. White areas in the drum membrane 
indicate calcification. A waxy appearance signifies the absence of 
air in the tympanum and is often associated with the presence of fluid. 



EXAMINATION OF PATIENTS. 501 

Texture. — The normal drum membrane is a thin, fibrous mem- 
brane, which, because of its fibrillated structure, is slightly opaque. 
The membrane may be abnormally thin and translucent or abnor- 
mally thick and opaque. The abnormally translucent conditions 
indicate a deficiency of the connective tissue fibers and an atrophic 
condition. The thick, opaque conditions may be due to calcification, 
edema, cellular infiltration, and inflammation. 

The normal position of the membrane is indicated by the position 
of the hammer handle, the short process, posterior fold and light 
reflex. The short process of the normal membrane appears as a 
slight protuberance at the upper end of the hammer handle. In 
a normal membrane, the hammer handle forms nearly a right angle 
with an imaginary secant which has the short process of the hammer 
for its central point, and runs between the spina tympani major and 
anterior. In a normal membrane, the posterior fold is scarcely 
perceptible. The light reflex is a cone of light with its apex at 
the umbo, and extending three-fourths of the way into the periphery. 

Abnormalities of position of the membrane are depression, 
retraction, extension and overdistention. When the drum head 
is depressed or retracted, the handle of the hammer goes backward 
and upward, making an acute angle at the short process. In this 
position the handle is perspectively foreshortened. Retraction 
of the membrane is also shown by elevation of the umbo and by the 
lengthening of the light reflex. In the depressed membrane the 
short process of the hammer becomes abnormally prominent, and 
may develop a supernumerary light reflex. The posterior fold 
of the membrane, which normally is not conspicuous, appears as 
a distinct ridge, extending backward and downward from the short 
process of the hammer, and may develop a supernumerary light 
reflex on its edge. 

With distention or extension of the membrane the handle of 
the hammer comes downward and forward, forms more nearly a 
right angle at the short process than in a normal membrane, and 
is proportionately lengthened in perspective. In overdistention, 
supernumerary reflexes may appear in various parts of the mem- 
brane, usually in the upper posterior quadrant near the margin, 
which is the weakest part of the membrane and is more apt to give 
way. The short process no longer protrudes, the posterior fold 
is entirely obliterated, and the light reflex is lost. 



502 DISEASES OF THE NOSE, THROAT AND EAR. 

. The outer surface of the membrane is normally smooth, glistening, 
and concavo-convex, with an umbilicated center. Contraction of the 
membrane, or flattening of its surface, is indicated by the change 
in the light reflex, which becomes very small and finally disappears 
altogether. Abnormality of the concavo-convex curve of the 
membrane is also indicated by the changes in the light reflex. 
There may be a break, forming two reflexes, or the reflex may be 
close to the umbo or at the periphery of the membrane. The 
light reflex always occurs on the most convex portion of the drum- 




FlG. 2IO. 

I. The axis of the hammer handle. 2. Secant across the incisura Rivini. 3. Poste- 
rior fold of the drum membrane. 4. Umbo. 5. Supernumerary light reflex. 6. 
Light reflex. 7. Short process of hammer. 

a } A right drum membrane extended showing wide angle between 1 and 2, and 
supernumerary light reflex in upper posterior quadrant of drum membrane. 

b, Left drum membrane retracted, showing narrow angle between 1 and 2, and super- 
numerary reflex at border of anterior lower quadrant of membrane, and another super- 
numerary light reflex on the short process of the hammer. 

head. Note should be made of unevenness of the membrane 
surface caused either by undue prominence or depression of portions 
of the surface. Unevenness is usually indicated by supernumerary 
light reflexes on the summits of the prominences or edges of depres- 
sions. Local depressions of the surface, due to scars and adhesions, 
sometimes occur; the margins or sides of the depression usually 
show supernumerary reflexes. These depressions are sometimes 
turned into protuberances after tympanic inflation, making corre- 
sponding changes in the supernumerary reflexes. The surface 
of the drum membrane is sometimes changed from the normal 
which gives a bright, glistening reflex, to a powdery, dull surface, 



EXAMINATION OF PATIENTS. 503 

giving a dull reflex or no reflex at all, or to a damp, shiny surface 
which gives a reflex from the surface of the moisture. If the inner 
end of the canal is wet, the light reflex is given from the side of the 
concave end of the canal formed by the capillary collection of fluid 
in the angle formed by the membrane and the walls of the canal. 
The surface of the membrane in severe acute cases is distorted and 
extremely distended, often extending nearly to the cartilaginous, 
meatus. In less extreme cases there may be bullae of considerable 
size on different parts of the membrane and adjacent canal. Natur- 
ally, under these conditions, all landmarks are obliterated. The 
bulging portion of the membrane is always the posterior half which, 
because of the oblique position of the membrane, lies between the 
observer and the anterior half of the membrane. 

The continuity of the membrane is examined to determine whether 
there are any perforations, and, if these are found, their size, posi- 
tion, and the character of their margins should be carefully noted. 

Examination of the Tympanum. — The tympanum should first 
be inspected through the meatus. The color of the inner wall 
of the tympanic cavity often shows through the membrane, as a 
pale yellow, as a pink luster, a dark reddish-blue tint, or a venous 
blue. The promontory is the part of the inner wall which imparts 
the color effect, and the color is, therefore, more marked in the 
posterior part of the membrane than in the anterior. The oval 
and round pelves and tip of the long process of the incus are usually 
visible through the normal drum membrane, and are very distinct 
through a thin drum membrane. The position of the pelves is 
indicated by small shadows behind the manubrium. • The oval 
pelvis is close to the upper posterior periphery of the membrane; 
the round pelvis is just below the oval pelvis and behind the umbo. 
The long process of the incus is seen as a faint yellow line, parallel 
to the .handle of the hammer, and close behind it. The long process 
appears much shorter. than the handle of the hammer. If there are 
perforations in the drum membrane, further details of the tympanic 
walls and contents can be noted. The presence of discharge in 
the tympanum, its nature, qualities and source are to be noted. 
Crusts, epithelial masses, granulation tissue and polypi arc to be 
looked for. The presence of granulations indicates long-standing 
irritation from suppuration, epithelial decomposition, carious bone. 
or foreign bodies. 



504 



DISEASES OF THE NOSE, THROAT AND EAR. 




i. Normal right tympanic membrane. 

a, Myringotomy. The line of incision of the upper edge of the membrane and 
upper posterior canal walls; b, the line of incision in the membrane vibrans. 

2. Normal left membrane. 3. Retracted left membrana. 4. Fluid in tympanum, 
right membrane. 5. Right membrane, showing swelling and drooping of Shrapnell's 
membrane. 6. Left membrane overdistended, showing bulging of posterior half of 



EXAMINATION OF PATIENTS. 505 

Examination of the Eustachian Tube.— The nasopharyngeal 
examination is very important, and has already been described by 
Doctor Knight. The patency of the tube is a vital point and 
must be determined by careful examination. The first test is by 
Valsalva's inflation. While the patient is performing this inflation, 
the observer should watch the drum membrane and observe any 
motions that follow the inflow of air, and also note the amount of 
pressure required to overcome the resistance of the tube. If more 
than slight pressure is required, it means that the tube is, at least, 
slightly closed. The amount of obstruction is in proportion to 
the difficulty of blowing air through the tube into the tympanum. 
By the use of the auscultation tube in Valsalva's method, the observer 
is enabled to determine the caliber and contents of the tube, the 
condition of its walls, and also the nature of the contents of the 
tympanum. 

The character of the auscultation sounds, as indicating compara- 
tive distance, indicates the locality of the structure; e. g., a constric- 
tion at the isthmus gives a much nearer sound than one midway 
in the cartilaginous tube. The degree of roughness of the ausculta- 
tion sounds indicates the nature of the tubal surface; e. g., a wet 
tube, or one covered with sticky mucus, gives crackling sounds of 
different pitch, the higher note coming with the thinner moisture. 
Auscultation sounds given by a fluid in the tube are crackling and 
bubbling rales, which are coarse for fluid containing much mucus. 
The sounds given by a tympanum containing fluid are not as loud, 
but the bubbling is more distinct. 

Politzerization is used if air will not go through the Eustachian 
tube by Valsalva's method. The sounds in Politzerization are 
of the same significance, but are more distinct. The auscultation 
sounds indicate the size of the passage, the location of the greatest 
obstruction, the nature of the tubal surface, and the presence of 
fluid. The size of the passage is indicated by the fullness of the 
entering air-blast. 

membrane. 7. Right membrane with large perforation, showing granulating surface 
of the promontory, a large polypus from epitympanum tills the upper anterior part of the 
field. 8. Large destruction of left membrana vibrans, exposing a granulating promon- 
tory, the handle of the hammer is exposed, characteristic of tuberculous tympanitis. 
9. Right membrana with perforation of Shrapnell's membrane and protruding granu- 
lations. 10. Left membrana contracted with three areas of calcification. 1 1. Com- 
plete destruction of left membrane vibrans and exposure of inner wall of tympanum. 
Oval and round windows can be seen, stapes and incus have disappeared, a stump of the 
hammer remains. 12. Exostoses are seen in the canal through the speculum. 



506 DISEASES OF THE NOSE, THROAT AND EAR. 

If air does not go through the tube by Politzerization the tube is 
physiologically closed, and the test must be made with a catheter. 
In catheterization, the character of the auscultation sounds, is 
noted by the otoscopic tube as in Politzer's method of inflation. 
The sounds are of the same significance, but more prolonged. 

Changes in Appearance of the Drum Membrane upon Inflation. — 
Normally, upon inflation, the drum membrane together with the 
umbo moves slightly outward. If inflation causes no movement of 
the membrane, it is abnormally rigid. If the membrane moves 
and the umbo remains stationary, the hammer is abnormally rigid. 
Laxity of the drum membrane is shown by indication of over- 
distention, which is usually shown by supernumerary light reflexes 
in the upper posterior quadrant of the membrane. A waxy mem- 
brane, when inflated, assumes a pearly color. If there is fluid in 
the tympanic cavity, its upper margin will probably become visible 
or the outlines of bubbles will be apparent. The part of the mem- 
brane above the fluid line will be pearly, while that below will retain 
its waxy tint. It is sometimes necessary to use a Siegei's otoscope 
to observe the motion of the hammer handle. By observation 
of the hammer handle, while condensation and rarefaction are 
made with the bulb of the otoscope, the degree of motion of the 
handle and membrane is readily noted. The normal mobility 
of the membrane is very slight. 

Functional Tests. — Functional tests should be applied before 
manipulatory treatment has been employed, and repeated after 
the treatment to further establish the diagnosis. The tests are 
made to determine the power of hearing or the hearing distance 
and acuity, and the range of hearing or the auditory field. The 
voice is, functionally, the best means for distance tests, but its 
inaccuracy and the difficulty of providing space for its use makes 
the use of a watch or Politzer's acoumeter more practical. For 
very deaf persons, however, we can use the whispered voice, using 
binomials, 26, 34, 87, and so forth. The whisper is made from an 
empty chest, after normal expiration. If the whisper is not heard, 
the ordinary voice or very loud voice is tried, according to the deaf- 
ness of the patient. The observer must have had much practice 
in order to gauge the carrying power of his voice. It is absolutely 
necessary that the patient should not see the observer's face during 
these tests. Each ear should be tested separately, the patient turning 



EXAMINATION OF PATIENTS. 507 

one ear after the other toward the observer. If there is unilateral 
deafness, the normal ear should be hermetically closed during the 
tests of the other ear. This can be done by the patient inserting 
the moistened finger-tip firmly into the ear, or an assistant may 
dampen the meatus and press firmly against the tragus, thus 
hermetically closing the canal. In order to prove that the patient 
hears with the ear under examination, this ear is also stopped while 
the test continues. If the patient now no longer hears, it proves 
that in these tests he heard with the ear under examination and not 
with the sound ear. The patient should be made to repeat the test 
words which he hears. The results of the examination are expressed 
in a fraction. The numerator is the distance at which the sound is 
heard and the denominator the normal distance for hearing the 
sound. 

The watch is a more practical distance test than the voice. The 
watch must always be held in the same manner by the observer, 
since the change in position makes great difference in the carrying 
power. The observer should suspend the watch by the handle 
between his thumb and finger, and turn the face of the watch toward 
the patient. The patient should thoroughly understand beforehand 
the part he is to play in the test, and the nature of the test. The 
yard-stick is a convenient measure in the examinations. When 
the patient's eyes have been shielded, the watch can be approached 
from beyond his hearing range. The distance is noted at the point 
when the patient first perceives the watch. Then the watch is 
slowly withdrawn and the distance measured when the patient 
loses the tick. The watch is approached to the ear for the second 
time until the patient again hears it, and the distance noted. The 
results are expressed by a fraction, for example, I5 ~^~ 23 ^ 
The 15 expresses the distance of the first observation, 29 the distance 
of the second observation, and 23 the distance of the third observa- 
tion. The denominator, 50, represents the normal hearing distance 
for the individual watch. The number 15 is a relative measure 
of the functional powers of the auditory centers. To find the 
absolute measure of the power of the auditory center, find the per 
cent, this number 15 is of 23, the last test. This gives 65 per cent., 
which indicates the efficiency of the higher auditory centers. The 
deficiency in the auditory centers, may be either perceptive or 
eoneeptivc. The number 29 is the measure of the major hearing 



508 DISEASES OF THE NOSE, THROAT AND EAR. 

distance. The number 23 is the measure of the minor hearing 
distance. The difference between 29 and 23, that is, 6, is the 
measure of the accommodative defect of the ear plus the after- 
impression hearing, if any exists. The absolute measure of the 
accommodative efficiency is found by getting the per cent, which 
23 is of 29. 

The presence of after-impression hearing is determined by 
rapidly withdrawing the watch beyond the hearing distance, and 
noting if the patient still hears it when it is obviously beyond his 
true hearing distance, as shown by the previous test. 

The chief use of the watch test is to give a ready means of measur- 
ing the change in hearing during the course of treatment. If the 
watch is not heard, the Politzer acoumeter is used with the same 
technic. Rapidly varying hearing distances are an indication 
of vasomotor instability. Diminished hearing distance indicates 
disease of the outer, middle, and inner ears, and of the auditory 
centers. Proportionately poor hearing for the voice, compared with 
the watch and acoumeter, indicates loss of lower tone perception, or 
deficient cortical perception. Proportionately poor hearing for 
the watch and acoumeter, compared with the voice, indicates loss 
of high tone perception. 

The auditory field is next determined. For the tests to determine 
the low limit of tone perception, a tuning-fork, say C 2 , is taken 
and sounded close to the concha. If the patient hears a distinct 
note, the next lower octave is tried, until a fork is found which is 
not heard as a distinct musical note. Working up again by slow 
degrees, from the fork that was not heard, the lowest audible note 
is determined. The result is expressed in the rate of vibration of 
the lowest note heard, say 64 single vibrations. The human voice 
is best heard by persons who have good perception for low notes. 
A disproportionately large loss of low tones indicates an impairment 
of the sound-conducting mechanism of the middle ear and external 
canal. The high limit of tone perception is determined with 
Edelmann's Galton whistle. Beginning at a high pitch, the pitch 
is gradually lowered until the patient hears a definite squeak or 
whistle. If the upper range of hearing is below the low limit of 
this whistle, the upper tuning-forks are necessary to determine the 
upper limit of tone perception. A disproportionately large loss 
of high tones indicates a defect in the nervous mechanism. 



EXAMINATION OF PATIENTS. 509 

The Tests for Relative and Absolute Air and Bone Conduction and 
for the Efficiency of the Auditory Nerve. — Take a fork of 192 single 
vibrations, if the patient can hear it, or a fork of a higher pitch, 
if necessary; the normal time that the forks can be heard must 
have been determined previously. The fork must then be set in 
vibration with a constant momentum. In order to gain a constant 
momentum in a fork of low pitch, the prongs should be pinched 
together and then allowed to snap back as they are drawn through 
the ringers; for forks of high pitch, the fork should be struck against 
the knee with a constant force. A stop watch should be used to 
register the time of hearing of the patient. For the air conduction 
test, approach the prongs of the tuning-fork close to the concha. 
In order to avoid neutralization of the sound by the interference of 
the waves from the two prongs, direct the flat of a prong toward the 
meatus. In all tests use the same position and the same distance. 
The patient is instructed to raise the right hand when the fork 
is heard and lower it when it is not. The observer, at an interval 
of a few seconds, approaches the fork to the patient's ear, and re- 
moves it again until the patient no longer raises the hand, when the 
fork is approached to the ear. The watch registers the length of 
time the fork is heard. 

Test for Bone Perception. — The fork is sounded with a constant 
impulse, and its stem placed on the mastoid behind the meatus. 
The fork is alternately lifted and replaced until it is no longer heard 
and the length of time during which it is heard noted. 

A rough method of getting an approximate test of air and bone 
conduction hearing is for the observer to compare the patient's 
hearing for the fork with his own; first testing the patient's hearing, 
and when the patient no longer hears the fork quickly trying his 
own ear with the fork. If the observer hears the fork, it means 
that the patient's hearing is less than the observer's. If the observer 
does not hear the fork, he should test his own hearing first, and 
when he loses the sound, apply the fork to the patient's ear to see 
how much longer the patient hears it than the observer. If there 
is doubt as to the results of the tests, they can be verified by placing 
the sounding fork against the median line of the head, on the apex. 
the glabella and the teeth. The patient should refer the sound to 
the side of the head that gave the longest time for bone conduction 
in the previous tests. These tests enable the observer to determine 



5IO DISEASES OF THE NOSE, THROAT AND EAR. 

the relative condition of the nerve mechanism and the conducting 
mechanism. With defect of the nerve mechanism, the bone conduc- 
tion is shortened. With defect in the middle ear sound-conduct- 
ing mechanism, the time for bone conduction is proportionately 
lengthened. The efficiency of the nerve mechanism is indicated by 
the result of the time of aerial hearing multiplied by the time of the 
bone conduction hearing. Normal hearing in middle life is about 
twice as long for air as for bone conduction. The bone conduction 
decreases gradually until old age, when it is usually absent. 

Examination of the Vestibular Apparatus. — There are three chief 
tests for increased or diminished vestibular reaction: 

i. The patient should be rapidly rotated on a stool from six 
to eight times. Normal reaction during rotation is nystagmus in 
the direction of the rotation. Vertigo and nystagmus in a reverse 
direction are apparent when the rotation is stopped. When the 
vestibular apparatus is destroyed or paretic, there is an absent or 
diminished reaction toward the affected side. With a hyper- 
sensitive vestibular apparatus, there is a spontaneous vertigo and 
nystagmus toward the affected ear, plus the normal reaction for the 
tests, which results in an increased reaction toward the affected side. 

2. The ear may be syringed with water slightly colder or hotter 
than 98. 6° F. With the colder water vertigo and nystagmus 
are apparent when the patient looks in the direction of the ear not 
syringed; with the warmer water, the nystagmus is apparent when 
the patient looks in the direction of the syringed ear. When the 
vestibular apparatus is destroyed or paretic there is an absence of 
reaction or a diminished reaction when the affected ear is syringed. 
With a hypersensitive vestibular apparatus there is an increased 
reaction upon syringing the ear. 

3. The air in the external canal may be compressed and rarefied 
by a Siegel's otoscope. If there is a fistulous opening in the 
vestibular capsule, this compression of the air will cause vertigo 
and nystagmus toward the affected side, provided the vestibular 
apparatus is not paralyzed. 

When the loss or impairment in the vestibular apparatus is recent, 
there is a nystagmus toward the normal side equivalent in amount 
to the unbalanced irritability. This nystagmus is similar in ap- 
pearance under .tests to the nystagmus of a hypersensitive vestibular 
apparatus. 



EXAMINATION OF PATIENTS. 51I 

Examination for Subjective Symptoms of Ear Disease. — The sub- 
jective symptoms of ear disease are very numerous and varied. 
The symptoms comprise every conceivable sound impression, variety 
of tone, pitch, and quality, every variety of pain in the ear and every 
discomfort in the head. These symptoms are variable and must 
be interpreted with a great deal of caution. They serve only as 
supplementary aids to the objective examination. The four 
classes of subjective symptoms include those referable, i. to the 
cochlear apparatus, 2. to the vestibular apparatus, 3. to the middle- 
ear apparatus, and 4. to the nerves of general sensation which 
are connected with the ear. 

Among the most important of these subjective symptoms are: 
Subjective vertigo, in which the symptoms relate to equilibration; 
with this symptom there is a feeling of dizziness not sufficiently 
marked to be observed on objective examination. Tinnitus, when the 
symptoms are subjective, and when the sounds noted by the patient 
are corporeal sounds. (See Physio-Pathology, Chapter XXVII, 
p. 477.) Otalgias are due to inflammations, swelling, the pressure 
of foreign bodies, and to reflex causes. Paresthesias, when the 
symptoms are abnormal feelings, not directly referable to hearing 
or pain. They are: itching in the ear; a drawing feeling; a full 
or heavy feeling; a feeling of distention; a feeling of motion, as of 
an object moving inside the ear; puffing or pulsating; snapping and 
cracking, bursting, intense, irregular thumping and pounding in the 
ear. Dysthesias: Various mental and sensory head disturbances, 
among them auditory hallucinations, aprosexia, and a great variety 
of cephalgias. 

Acute inflammation of the middle-ear cavity or of surrounding 
bone requires the observation of the pulse and temperature. A 
temperature chart is kept while the process is active for comparison 
of the curves. A bacterial examination of the intratympanic pus 
should be made in infectious cases, in order to more definitely 
establish the prognosis, and to furnish more definite indications for 
treatment. The bacterial findings in the non-contaminated contents 
of the tympanum or mastoid cells are of considerable significance. 
(See Chapter XXVII.) The differential blood count should be made 
in all complicated middle-ear infections. Although the blood 
count usually is of comparatively small use in ear disease because 
of the superficial seat of the inflammation, it may be of service in 



512 DISEASES OF THE NOSE, THROAT AND EAR. 

determining the existence of suppuration. If the suppuration is 
not located elsewhere, the presence of an inflammatory disturbance 
of the ear, which always gives local signs, indicates that the ear is 
responsible for the blood findings. 

Diagnoses of ear disease, while comparatively simple in nature, 
are complicated and difficult in practice, because of the many 
different pathological changes which are often found in the same 
ear. The superficial conditions are seen on inspection. Discharge, 
swelling, or tenderness that have a deep-seated origin require further 
study. The conditions of the canal are seen at a glance. The 
drum membrane, if visible at all, can be immediately described. The 
condition of the Eustachian tube is determined in a few moments by 
simple tests. The nature of the contents of the tympanum is indi- 
cated by the appearance of the drum membrane and auscultation 
sounds. The absence of tympanic inflammation is indicated by 
the absolute pallor of the drum membrane and osseous canal. The 
condition of the middle ear sound conducting mechanism is deter- 
mined by functional tests. A decrease of air and increase of bone 
conduction indicate obstructions of sound transmission. The 
cause of this impeded sound transmission is determined by the 
findings in the external meatus, drum membrane, and Eustachian 
tube. The cochlear nerve affections are determined by lessened 
distance hearing, shortened bone conduction, and loss of high 
tone perception. Vestibular nerve disturbances are indicated by 
alterations in the reaction of the equilibrational mechanism — 
whether of increased reaction or changed reaction. The gravity 
of an ear infection is determined on inspection, which shows dis- 
tention of the membrana tympani. violent congestion, blebs, swelling 
of osseous canal, mastoid swelling, and by the constitutional reaction. 
The presence of mastoiditis is indicated by superficial periosteitis; 
periosteitis of the posterior wall of the osseous canal; pain in- 
creasing on deep pressure over the emissary vein or posterior 
end of the digastric groove; pain increasing on deep pressure over 
the mastoid antrum, in connection with other symptoms; febrile 
reaction and septic symptoms without sufficient cause apparent 
in other organs, and the indication of any inflammation present 
in the middle ear, or even in the history of a middle-ear inflamma- 
tion within two months. The presence of meningitis is indicated 
by continued high temperature, headaches, and other intracranial 



EXAMINATION OF PATIENTS. 513 

disturbances. Sinus thrombosis is indicated in connection with ear 
disease by rapid fluctuations of a high temperature and by the 
presence of streptococci in the blood. Brain abscess is indicated 
by focal symptoms, in combination with ear infection; also when 
there are intracranial signs of inflammation with past or present 
ear infection without symptoms of new growth or sinus thrombosis 
and meningitis. 

After a careful examination of the general condition of the 
patient and of the ear, the pathological condition of the ear may 
be determined with accuracy and with little difficulty. The 
first indication for management of the case after the examination 
is the removal of the cause of disease, not omitting to make a record 
by which the improvement of the local pathological conditions can 
be gauged. 

AUTHOR'S BIBLIOGRAPHY. 

Tinnitus Aurium: Diagnosis and Differentiation. Trans. Am. Otological 

Society, New Bedford, 1904, vol. viii, part 3, pp. 385-396. 
Practical Hearing Tests. Jour, of Ass'n. Military Surgeons of the U. S., May, 

1905, vol. xvi, pp. 245-251. 
Differential Diagnosis of Different Forms of Deafness. Archives of Diagnosis, 

New York, April, 1908, vol. i, No. 2, p. 163. 
Tests of Hearing. Dr. C. H. Burnett's System of Diseases of the Ear, Nose, 

and Throat. J. B. Lippincott, Phila., 1893, v °l- h P art I > PP- 5 2_ 98. 
Tinnitus Aurium and Hallucinations of Hearing, or the Relationship of Ear 

Disease to Auditory Hallucinations of the Insane. Jour, of Laryn., 

Rhin. and Otol., London, vol. xv, 1905, p. 485. 
Le Retrecissement de la Trompe d'Eustache dans les Maladies de 1' Oreille 

et son Traitement. Ann. de Mai. de l'Oreilles de Lar. et Phar., 

Paris, 1906, vol. xxxii, pp. 25-29. 
Aural Inspections and Functional Tests in Healthy Individuals A Plea for 

the Prevention of Deafness. N. Y. State Jour. Med., Albany, July, 1907. 

vol. vii, No. 7, p. 270-272. 
Diagnosis of the Presence of Predisposing Conditions Favoring the Establish- 
ment of Otorrhea. .Archives of Diagnosis, New York 1909, vol. i. 
A Phonographic Acoumeter. Trans. Am. Otol. Society, New Bedford, 1904, 

vol. viii, part 3, pp. 520-522. 



33 



CHAPTER XXX. 

AFFECTIONS OF THE EXTERNAL EAR. 

AFFECTIONS OF THE AURICLE. 

MALFORMATIONS AND DEFORMITIES. 

Congenital malformations of the auricle, which are liable to be 
hereditary, include the following: hypertrophia auris, or abnormal 
development of the ear; scroll ear, in which the auricle is crumpled 
forward; polyotia, in which there are imperfect attempts at develop- 
ing additional cartilaginous nodules in the neighborhood of the ear; 
microtia, where the size of the auricle is much reduced; and anotia, 




Fig. 212. — Microtia and polyotia of the left ear. The small supernumerary cartil- 
age lies in front of the small crumpled attempt at the growth of a pinna. 

where the auricle is absent. The two latter conditions are usually 
associated with abnormal external canals. Anotia, either congenital 
or accidental, is best rectified by an artificial rubber auricle. For 
the other malformations of the auricle, the only treatment is surgi- 
cal (see chapter "Surgical Technic"). The auricle may be more 
prominent than is normal, or the cartilaginous folds may be 
irregular. 

5i4 



MALFORMATIONS AND DEFORMITIES. 515 

The branchial cyst or fistula, which is a rudimentary organ, is 
a remnant of an embryonic branchial cleft. The persistence of 
the cleft is of rare occurrence (see Fig. 150). These fistulas are 
very narrow, tortuous capillary tubes, opening superficially in front 
of the auricle, and leading inward toward the middle-ear tract, 
with which they sometimes connect. The persistence of these 
fetal structures occasionally becomes surgically important, owing 
to the chronicity of the inflammation following infection and the 
possibility of malignant degeneration in later life. In these cases 
excision is the only treatment. 

Deformities due to inflammation, such as those following chon- 
dritis or traumatic loss of tissue, are very difficult to remedy surgically 
on account of the difficulty of grafting cartilage. 

Injuries. — The position of the auricle exposes it to wounds, and 
to injuries from incision, amputation, contusion, frost-bites, and 
burns. 

Wounds. — The treatment of wounds requires special antiseptic 
care to prevent infection. Especially rigid antisepsis is required 
because of the deformities which may result from perichondritis and 
chondritis. The parts should be carefully cleaned and put in 
position. If necessary, sutures should be used to keep the parts in 
place. If there is not much displacement and if the parts are not 
infected, they should be covered with a collodion dressing. If 
there is question of infection having taken place, a gauze dressing 
should be applied and the ear bandaged to the side of the head. 
If the wounds show signs of inflammation, free drainage should 
be provided and the ear done up in a wet dressing of aluminum 
wash (No. 12, page 592). 

Contusions of the auricle may result from slight blows and are 
very apt to assume a special pathological form, i.e., separation of 
the anterior perichondrium of the cartilage, with the subsequent 
formation of a cyst, which may be filled with blood or serum. 
These blood cysts, called othematoma, while they may heal spontane- 
ously, often become infected; in case of infection, the resulting 
perichondritis and loss of cartilage causes serious deformity oi 
the auricle. 

Frost-bites of the auricle are common, and. while there is no 
special treatment for the car other than thai which the skin of any 
part of the body would receive under similar conditions, the danger 



5*5 

from perichondritis and chondritis must be borne in mind. Embro- 
cation of aluminum wash No. 1 2 should be used in the treatment 
of frost-bites. 

Burns and scalds should receive treatment similar to that used 
for frost-bites. 

DISEASES OF THE AURICLE. 

Affections of the Skin. — The cutaneous lesions most frequently 
occurring on the auricle are: eczema and dermatitis parasitica from 
the irritation caused by pediculosis capitis; eczema and dermatitis 
caused by excoriating discharges of otorrhea; eczema, acute and 
chronic, from other causes; dermatitis phlegmonosa and gangrenosa; 
impetigo contagiosa and lupus vulgaris. Syphilitic skin lesions 
include primary lesions; tertiary lesions are not common. Treat- 
ment requires local cleanliness and constitutional antisyphilitic 
remedies. Cutaneous lesions of the auricle do not differ, either in 
etiology, diagnosis, or treatment, from similar lesions in other 
parts of the body; except in the cases where there is a special etio- 
logical factor, such as excoriating discharges, or pediculosis capi- 
tis, in which event the treatment must be adapted accordingly. 
Eczema will not yield to treatment until the cause has been removed. 

Erysipelas of local origin is due to infection originating in a 
purulent ear, and should receive, in addition to the aural treatment, 
appropriate treatment for erysipelas. 

Perichondritis and chondritis are very important diseases of the 
auricle and should receive attention as soon as any symptoms 
of thickening of the auricle are apparent. In the early stages of 
perichondritis, the auricle should be treated with a wet dressing of 
aluminum wash No. 12. If the process has developed to the suppura- 
tive stage, very free incisions should be made down to the cartilage 
in order to insure perfect drainage, and the same wet dressing 
continued. 

Abscess of the auricle is treated by incision, wet dressing of 
aluminum wash No. 12, and surgical drainage. 

Hyperemia of one or both auricles, if not of traumatic origin, is 
due to vasomotor instability, which will be relieved when the 
sympathetic nerve centers are in a healthy condition. 

Herpes zoster is worthy of special notice, since its presence 



AFFECTIONS OF THE EXTERNAL AUDITORY CANAL. 517 

indicates a lesion in the geniculate ganglion and facial nerve. 
The association of these nerves with, the auditory nerve in the 
internal auditory meatus accounts for the presence of frequent 
auditory symptoms in herpes. The earache is usually extreme 
before the herpetic eruption appears. The diagnosis is frequently 
obscured by the treatment applied for the relief of the pain. 

NEOPLASMS. 

Neoplasms of the auricle include lipoma, fibroma, keloid, papilloma, 
cystoma, angioma, osteoma, carcinoma, and sarcoma. Benign 
tumors should be removed if they cause deformity or obstruct 
the canal. Early operations for malignant tumors give good progno- 
sis. Epitheliomata yield readily to the X-ray. 

AFFECTIONS OF THE EXTERNAL AUDITORY CANAL. 

The affections of the cartilaginous auditory canal are in many 
respects similar to those of the auricle. 

The congenital malformations of the canal are absence of the canal 
and atresia. Since the defect is apt to increase toward the middle 
ear, treatment of this latter condition is not usually effective. Any 
operative attempts at opening up the middle ear are apt to fail 
because the middle-ear structures are very rudimentary. Traumatic 
stricture or obliteration of the canal is easily rectified by surgical 
means (as described under Surgical Technic, Chapter XXXVI). 

In injuries of the external canal, such as incisions, lacerations, 
contusions, and burns, the possibility of resulting atresia should 
not be lost sight of. When dry treatment with antiseptic powders 
is not sufficient to control the discharge, douching with warm 
antiseptic solution should be employed. Packing is not desirable 
except when it is necessary to hold shreds of epidermis or periosteum 
in position. 

The presence of foreign bodies in the canal is one of the most 
common causes of ear affections of local origin. Immediate danger 
is not caused so much by the objects themselves as by injudicious 
treatment in their removal. There are recorded cases where foreign 
bodies have remained in the ear for years without any untoward 
symptoms. Small bodies in the cartilaginous canal are easily 



518 DISEASES OF THE NOSE, THROAT AND EAR. 

removed with the ring curette or forceps. If the body is near the 
drum membrane it may be syringed out with little inconvenience 
to the patient. If the bodies are large they may usually be removed 
with the least damage by the syringe, aided by a hook or ring curette. 
Foreign bodies of such a nature that they will swell, such as beans 
and peas, should be removed as soon as possible. If the impacted 
body cannot be removed by the above methods it may be morcelled 
away with the forceps. If. however, it is too hard to be broken up. 
it may have to be removed by operative means see Surgical Technic, 
Chapter XXXVI . 

The difficulty of removing foreign bodies is often increased by 
previous injudicious and unsuccessful attempts at extraction. 
resulting in laceration of the canal, perforations of the drum mem- 
brane, suppurative otitis media, mastoiditis, etc. Swelling and 
infection of the canal are annoying obstacles to the removal of the 
body. The presence of accumulations or foreign bodies in the ear 
may excite a very annoying reflex spasmodic laryngeal cough. 

Occasionally the hairs growing in the meatus are abnormally 
abundant and long, and instead of growing outward, may grow 
inward and touch the drum membrane, causing great annoyance. 
These hairs should be cut with nne scissors and removed with 
forceps. 

Disorders of Secretion of the External Auditory Canal. — The 
ceruminous secretion may be entirely absent, increased or diminished 
in quantity, nearly fluid, or very dense. The absence of ceruminous 
secretion is due to a degeneration of the secretory epithelium of 
the ceruminous glands. This condition is usually brought about 
by chronic eczema. 

The obstruction of the canal with cerumen, which may cause 
deafness, tinnitus, and vertigo, is due to improper toilet of the canal. 
to hypersecretion of cerumen, to abnormally viscid or hard cerumen, 
to an admixture of dust, or to an abnormally narrow canal. The 
prophylaxis of ceruminous impaction is directed to the relief of the 
cause. In improper toilet of the canal through mistaken ideas of 
cleanliness, when the cerumen is wiped out or picked out from the 
canal, a small portion of cerumen is pushed back out of reach. The 
result is that the residual cerumen accumulates, is packed in the 
inner end of the canal, and presses on the drum membrane instead 
of falling out of the canal. 



SUPERFICIAL INFLAMMATIONS OF THE CANAL. 519 

Hypersecretion of cerumen is the condition resulting when the 
cerumen is formed to such an extent that it clogs the external canal. 
Sometimes the abnormal amount of cerumen can be decreased by 
lessening any nasopharyngeal irritation. 

The ceruminous glands sometimes secrete abnormally dry or 
viscid cerumen, which tends to accumulate and form a plug at the 
mouth of the meatus. 

When an individual is continually subjected to a dusty environ- 
ment, such as in the occupation of coal-heaving, the dust falling 
into the orifice of the canal combines with the cerumen to form 
a thick mass which obstructs the canal. Accumulations of dust 
may be prevented by wearing a little cotton in the ears while 
exposed to a dusty atmosphere. 

The lumen of the canal is sometimes very narrow at the first 
fold of the cartilaginous canal, thus resulting in bringing the surfaces 
in apposition, in closing the orifice, and in preventing the cerumen 
from passing out. This condition is sometimes found in the aged 
after the atrophic changes have commenced. With an abnormally 
narrow canal, a very small amount of cerumen is enough to obstruct 
the canal. 

Treatment. — The cerumen, if in a small mass near the mouth of 
the canal, may be dislodged and removed with the ring curette. 
Soft pieces of cerumen can be wiped away. When cerumen is 
impacted in the canal, it can be removed with the ring curette or 
foreign body hook. When the cerumen is in the inner end of the 
canal and is adherent to the drum membrane, syringing is the best 
treatment. In removing large quantities of cerumen and in remov- 
ing abnormally viscid cerumen, the syringe should also be employed 
(see "Procedures," Chapter XXXVIII, page 602). The syringing 
is always the final resort in removing cerumen. 

SUPERFICIAL INFLAMMATIONS OF THE CANAL. 

DISORDERS OF THE KPITHELIAL EXFOLIATION OF THE 
CANAL. 

Eczema of the canal, either acute or chronic, and keratosis, 
cause a rapid exfoliation of epithelium which may block the canal. 
These affections may be due to injudicious cleansing, mechanical 
irritation, the presence of parasitic fungi. Infection, or vasomotor 



520 

disturbances of constitutional or nasopharyngeal origin. They 
are characterized by itching and exfoliation of epithelium. Chronic 
eczema of the canal frequently causes the destruction of the cerumin- 
ous glands. A chronic eczema may develop extensive desquama- 
tion, with a shedding of concentric epithelial casts of the canal. 
The exfoliated epithelium sometimes undergoes cholesterin degenera- 
tion and forms a true cholesteatoma; sometimes the epithelium 
becomes hardened, forming a horny plug or keratosis of the canal. 
As the epithelial plug is continually added to by new layers, it 
obstructs the canal, and causes absorption of the bony wall by 
pressure. 

Treatment for these affections consists in the dislodgment of 
the epithelium and the plugs, and the use of boric acid and alcohol 
solutions until the inflammation of the dermoid lining has subsided. 
The technic for the removal of the plug requires softening of the 
plug with alkaline solutions, or a solution containing a small amount 
of salicylic acid, syringing away the loosened particles and morcelle- 
ment of the core. Great care is necessary to avoid the swelling 
incident to manipulation of the canal, and the pain and tenderness 
consequent upon treatment. The removal of horny epithelial plugs 
is extremely difficult at times, and requires patience and care in 
order to avoid injury of the canal. In cases of epithelial plugs 
complicated by severe inflammation of the canal, the removal of the 
plug cannot be accomplished in one treatment, without administering 
an anesthetic. When the canal is dry and the itching is annoying, 
the best preventive of the itching is lanolin and creolin, i ounce 
to 3 mm., applied lightly to the canal walls. 

DEEP INFLAMMATIONS OF THE CANAL. 

The pathognomonic symptom of deep inflammation of the external 
canal is tenderness of the cartilage, which may be demonstrated 
by traction on the auricle or pressure on the tragus. 

Otitis externa circumscripta, or furunculosis, is a very common 
cause of earache. It occurs only in the cartilaginous canal, and 
is a purulent infection of the glandular elements and of cellular 
tissue. The infection may be inoculated from without by picking 
with the finger, or with an ear pick, or it may come in the purulent 
discharge from the middle ear. This affection is very painful to the 



DEEP INFLAMMATIONS OF THE CANAL. 52 1 

patient, and most annoying to the physician because of its tendency 
to recur. The strictest possible antisepsis must be practised. The 
sooner the furuncles are incised, the quicker the relief. Previous 
to incision, the best treatment is the application of camphophenique 
on cotton in the canal with dry heat about the ear. For dry heat 
use a hot-water bag or hot salt in a doughnut-shaped bag. After 
incision the pain is much relieved and will not recur unless a new 
center of suppuration arises. A hot douching with 1-2000 bichloride 
solution may be used every two hours, as long as the discharge 
continues. When the discharge has lessened, a little antiseptic 
dusting powder is all that is required. The furuncular abscess 
sometimes increases to considerable size, passes through the 
cartilaginous wall, and invades the tissues in front of the auricle. 
If the pus burrows backward, it inflames the epimastoid tissues 
to such a degree that the symptoms of mastoiditis are simulated. 

In otitis externa diffusa the canal is red and swollen, indicating 
an irritated condition due either to infection or to some irritant. 
The cause should be removed if possible and local treatment for 
the canal applied when the pain is annoying. The treatment should 
be accomplished with hot antiseptics, preferably douching with 
saturated aqueous boric acid solution. 

The external auditory canal is sometimes subject to inflammations 
from virulent infection. These may show hemorrhagic bullae at 
the inner end of the canal, croupous exudates, or diphtheritic 
membranes. Local treatment for the hemorrhagic process consists 
in dry treatment with insufflation of boric acid powder. In the 
membranous inflammations treatment consists in the use of bi- 
chloride solution — 1-1000 or 1-2000 — as a douche, and peroxide of 
hydrogen to dissolve the membrane. 

Inflammation of the dermo-periosteum of the canal often accompanies 
other inflammations of the canal as a complication; occasionally 
it is due to causes from, within, in which case it indicates the presence 
of osteitis and therefore, when occurring on the posterior and upper 
canal walls, is a most important symptom of mastoiditis. 

Inflammations of the External Meatus due to Non-bacterial 
Vegetable Parasites. — These inflammations are due to aspergilli, 
which occur in three species— black, yellow, and white. The 
symptom of their presence is the discovery of the mould. There 
is usually itching and superficial inflammation of the external 



?2 2 DISEASES OF THE NOSE. THROAT AND EAR. 

canal, which persists in spite of ordinary treatment. Diagnosis 
under these conditions is positive. The diagnosis is made absolutely 
positive when with the use of a microscope the spores and charac- 
teristic fibers of the aspergilli are found in the detritus removed 
from the canal. 

Treatment. — It must be borne in mind that spores of these 
aspergilli are very resistant, and even the dust of the room in which 
the patient lives may become a source of infection. The best 
method of destroying the spores in the ear is to syringe the ear with 
alcohol even- day for three days: this allows time for the last spore 
to germinate and to be killed by the alcohol: the spore itself is not 
injured by any ordinary reagent or usual antiseptic. 

Parasitic larvae or maggots in the canal are easily destroyed by 
instillation of alcohol, or tincture of iodine. 

EXOSTOSIS AXD HYPEROSTOSIS OF THE CANAL. 

Exostoses of the canal are of two varieties: the pedunculated 
type which occurs near the outer margin of the osseous canal: 
and the sessile, which occurs near the drum membrane. The 
etiology of the pedunculated form is not thoroughly understood; 
the etiology of the sessile form may be traced to a dermoperiostitis 
from local irritation usually due to the presence of moisture in the 
fundus of the canal. It is frequently found in individuals who 
get water in the ears from frequent bathing. These growths may 
occlude the canal, thereby giving rise to deafness, or they may cause 
retention of secretions which ferment and produce excoriations and 
suppuration of the canal, perforation of the tympanic membrane, 
otitis media, and mastoiditis. Treatment is directed to stopping 
the irritation due to the moisture. If. after the arrest of the exciting 
cause, the decrease in swelling is not sufficient to relieve all the 
symptoms the growth must be removed by surgical means. 

Hyperostosis of the canal is a diffuse thickening of the bone of 
the canal due to chronic irritation of the dermo-periosteum. Hyper- 
ostosis results in narrowing the passage of the canal. It is often 
syphilitic in origin. 

XeopJasms. — The neoplasms of the external auditor}- meatus 
are granuloma, fibroma keloids-, papilloma, cystoma, sebaceous 
cyst, angioma, carcinoma, and sarcoma. Granulomata are usually 



EXOSTOSIS AND HYPEROSTOSIS OF THE CANAL. 523 

polypoid growths of granulation tissue, rarely of tubercular or 
syphilitic origin. They usually originate in the middle ear, 
but sometimes grow from the walls of the canal. In either case, 
the granulation tissue is due to chronic suppuration. The polypi 
often protrude from the middle ear into the meatus. If these 
growths obstruct drainage, they should be morcelled away with 
biting forceps. The fibroma, papilloma, cystoma, angioma, and 
osteoma, if sufficiently large to obstruct the canal, require surgical 
removal. Since the diagnosis is seldom made until adjacent struc- 
tures are involved, the malignant growths of this region rarely 
offer a good prognosis. The treatment is extensive removal as soon 
as possible. 

Herpes zoster of the canal occurs on the walls of the canal and 
drum membrane. It is similar in cause, symptoms and treatment 
to herpes of the auricle. 

Myringitis, or inflammation of the drum membrane, is sometimes 
consequent on irritation or infection of the auditory canal. One 
of the common causes of dermatitis of the drum membrane is the 
aspergillus. When the condition is due to the presence of aspergilli 
the moulds should be exterminated by treatment with alcohol 
as previously described. When the inflammation is not due to 
aspergilli, dry wiping and insufflation of boric acid powder is the 
best treatment. The inflammation may spread through the 
drum membrane and into the middle ear and cause otitis media 
acuta. It may cause perforation of the drum membrane and 
allow the inflammation to enter the middle ear. The inflammation 
may be violent enough to extend through the tympanum and cause 
mastoiditis. 

Syphilis of the external canal shows itself in mucous patches, 
gummata, and dirty ulcerating surfaces. The treatment for this 
condition consists in the maintenance of cleanliness, antisyphilitic 
medication, and stimulation with a 10 per cent, solution of nitrate 
of silver. 

Suppurative fistula and bone caries sometimes occur in the canal. 
Fistulae are due to subperiosteal burrowing of pus from the middle 
ear, to mastoid inflammation which is draining through the canal 
wall, or to caries of the canal. The caries may be due to an extension 
of the mastoiditis, or to necrosis oi the bony part oi the canal from 
pressure or keratosis. 



524 DISEASES OF THE NOSE, THROAT AND EAR. 

Hemorrhage from the ear, when not of traumatic origin or due 
to ulceration, is of the nature of vicarious menstruation. This is 
a rare condition, and is due to the bursting of the tympanic vessels 
on the drum membrane along the hammer. Ulceration of the 
large vessels sometimes occurs in the course of suppuration of the 
middle ear and may result fatally. 

AUTHOR'S BIBLIOGRAPHY. 

Primary Syphilis of the Ear. Am. Jour, of Dermatology. July, 1906, vol. x, 

No. 7, pp. 271-274. 
Report of a Case of Fibroma of the External Auditory Canal with Serious Reflex 

Symptoms. Trans, of Am. Otol. Soc. New Bedford, 1903, vol. viii, 

part 2, pp. 305-7. 



CHAPTER XXXI. 

DISEASES OF THE MIDDLE EAR. 

Middle-ear diseases, viewed from a pathological and etiological 
point of view, may be classified in two main divisions: I. Otitis 
or inflammations, and II. Trophopathia tympanica or trophic 
changes. These two main divisions may be subdivided, on the same 
basis, into: 

I. Otitis, into i. otitis media catarrhalis nita or otitis nita; 
2. otitis media acuta virulenta or otitis virulenta; 3. otitis media 
purulenta chronica or otitis chronica; 4. otitis media tuberculosa, 
and 5. otitis media luetica. 

II. Trophopathia tympanica or trophic changes, into 1. trophic 
changes of inflammatory origin, including a. fibrosis tympanica, 
and b. sclerostenosis tympanica; and 2. trophic changes of vaso- 
motor origin, including a. hypertrophia tympanica or hyperemia 
tympanica chronica, and b. sclerosis tympanica or anemia tympanica 
chronica. 

I. Otitis. — 1. Otitis Media Catarrhalis Nita. — This group includes 
diseases of the middle ear, which show a mild degree of inflammation, 
including congestion and edema, possibly extending as far as hyper- 
mucous secretion and serous exudation. 

Etiology. — The causative factor is a mild infection entering 
through the tube from the pharynx, from the meatus through the 
drum membrane, from some irritant in the blood which is excreted 
through the mucous membrane, from traumatism or from the irrita- 
tion of the tympanum caused by acute closure of the Eustachian 
tube and from reflex irritation, especially of dentition. 

Pathology. — There is present a hyperemia developing into serous 
exudation, infiltration, mucorrhea, and stopping short of ulceration 
and suppuration. 

Symptomatology. — Objective Symptoms. — A slight pinkish tinge 
of the tympanic membrane and promontorial wall, with or without 
serous exudate into the tympanic cavity; edema of the mucous 
membrane with or without closure of the Eustachian tube; rales 

5 2 5 



526 DISEASES OF THE NOSE. THROAT AXD EAR. 

present or absent on inflation, depending on the presence of fluid 

and varying with the amount and consistency of the fluid in the 
tympanum. The drum membrane is not distended. Subjective: 
Pain may be absent or very slight, or there may be occasional sharp 
twinges: the tinnitus may be absent or very marked; the pitch of 
the tinnitus is low. and there is more or less feeling of weight and 
fullness in the ear. The hearing may be slightly or greatly reduced. 
The tone field is varyingly contracted, and is especially defective 
for the upper notes. Inflation usually relieves the symptoms for 
a time. Febrile reaction is usually slight, often absent. 

Diagnosis. — The diagnosis is made on the evidence of a mild 
inflammation in the tympanic cavity, congestion, swelling and 
exudation, without hemorrhage, or suppuration. 

Course. — The course is transitory or prolonged, according to 
the nature and continuance of the exciting cause. 

Treatment. — Treatment is first directed to relieving the swelling 
and obstruction of the Eustachian tube, which is best accomplished 
by applying 1-8000 solution adrenalin in a 4 per cent, solution 
cocaine on cotton applicators to the mouth of the tube through the 
nose. For tympanic drainage and for stimulation of the circulation, 
inflation should be performed, preferably by the Politzer method, 
by the catheter if Politzerization will not inflate, or by Valsalva's 
method if time is pressing. When there is fluid in the tympanum, 
the ear to be inflated should be placed in such a position that the 
Eustachian tube occupies a vertical position, with its pharyngeal 
end downward. To put it in this position, the patient bends the 
head forward 45 ° and turns the face 45° toward the side of the 
affected ear. The amount of inflation and the frequency of its 
application, are determined by the relief obtained and by the amount 
of irritation caused by the inflation, the object being to cause the 
greatest relief without any irritation. The instillation of hot saturated 
boric acid aqueous solution in the ear every hour or two. according 
to the urgency of the case, is useful to stimulate the circulation, 
to promote resolution, and to alleviate pain. The exciting cause 
of the inflammation is removed by nasopharyngeal treatment to 
allay any local infection or irritation, if that alone is the cause. 
The constitutional advantages of a laxative, such as a compound 
mixture of rhubarb and soda, are shown in the relief of the congestion 
of the tubal mouth. Reflex causes require appropriate manage- 



DISEASES OF THE MIDDLE EAR. 527 

ment. Constitutional treatment for any systemic disease having a 
causative relation, should receive immediate attention. Of the 
systemic causes, syphilis is a common one. The use of any drugs 
which irritate the mucous membrane should be discontinued. 

Prognosis. — The prognosis is good for speedy relief and permanent 
cure under appropriate treatment. 

Complications and Sequelce. — Complications are possible, owing 
to the fact that the inflammation may become virulent. Sequelae, 
other than those due to increased virulence of the infection, are 
the results of long chronicity. These are trophic changes, of an 
inflammatory origin, and later atrophic results, gradually leading 
to fibrosis tympanica, and later to sclerostenosis tympanica. 

2. Otitis Media Acuta Virulenta. — Otitis media acuta virulenta is 
a middle-ear inflammation, accompanied by suppuration or other 
signs of virulent infection. 

Etiology. — The cause of this virulent infection may be bacterial 
invasion from the nasopharynx, or very rarely superficial infection, 
bacteria or toxins carried by the blood, or traumatic infection. 

Pathology. — Characteristics of this inflammation are inflammation 
of the mucous membrane, advanced to the point of serous exudation, 
desquamation and separation of the epithelial layer, hemorrhage, 
suppuration, and ulceration. The strength of the bacterial toxins 
may be sufficient to cause necrosis. The invading bacteria, together 
with their toxins, may enter the general circulation. 

Symptomatology. Objective Symptoms. — There is an active 
inflammation of the drum membrane and tympanum, serous, 
hemorrhagic, or purulent. There are two types* — sthenic and 
asthenic. In the asthenic or cold type, the symptoms are those 
of suppuration without much reaction; the membrane is thickened, 
possibly bulging, and yellow, suggestive of pus within. In the 
sthenic variety, the signs of inflammation range up to the mosl 
violent forms where there are hemorrhagic bullae of the drum 
membrane and canal walls. The drum membrane is much 
thickened in all cases, extremely thick in some, and may be greatly 
distended from the intratympanic pressure. Perforations oi the 
drum membrane are the rule. These soon appear in the case- 
where drainage through the tube is not sufficient. The site of the 
perforations depends partly on the changes in the tympanum before 
the commencement of the inllammation, and partly on the location 






528 DISEASES OF THE NOSE, THROAT AND EAR. 

of the focus of the inflammation. The perforation occurs in the 
thinnest part of the membrane, or in the part of the membrane nearest 
the focus of the inflammation. In these cases, the perforations 
are of diagnostic value, indicating the location of the focus. Febrile 
reaction is slight or marked. The appearance of suppuration or 
of very active inflammation in the middle ear are rise in temperature 
and pulse rate, swelling and congestion, and the presence of pus 
or hemorrhage. Subjective Symptoms. — Usually extreme pain in 
the ear and its neighborhood; tenderness over mastoid and auricle 
is fleeting; tinnitus not often annoying. Hearing considerably 
reduced. Tone field contracted at both extremes. 

Diagnosis. — In a typical case the diagnosis is readily made on 
appearance of a violent tympanic inflammation, or an acute suppurat- 
ing condition; in the less typical cases, the febrile reaction and the 
history are sometimes necessary to make a diagnosis because of the 
obscurity of the tympanic symptoms. In a patient with asthenic 
or cold inflammation of the middle ear, with no marked signs 
of inflammation, it may be difficult to determine the presence of pus 
in the tympanic cavity without inflation and auscultation to demon- 
strate the presence of fluid, which the yellow or bluish tint of the 
membrane would denominate as pus. 

Course. — If the middle-ear tract, including the Eustachian tube, 
was in normal condition before the inflammation commenced, 
the infection will in all but rare cases run its course without rupture 
of the drum membrane or other complications, and with little or no 
damage to the tympanic membrane. A slightly obstructed Eusta- 
chian tube will predispose to perforation of the drum membrane 
and dangerous complications. The condition of the tympanum 
before the occurrence of the infection is important, since any 
changes that have obstructed drainage will tend to aggravate the 
middle-ear inflammation. Individual peculiarities of the temporal 
bone determine the sequelae that occur, since, if the infection spreads, 
it will travel in the direction of the least resistance and invade 
those organs and tissues which are most susceptible to the inflamma- 
tion. In this connection, the arrangement of the mastoid cells 
and the thickness of the mastoid cortex have an important bearing, 
since the pus will follow the direction of the cells and will break 
through where the cortex is thinnest, whether externally or internally. 
The influence of the previously-mentioned factors, together with 



DISEASES OF THE MIDDLE EAR. 529 

the influence of the environment and opsonic resistance of the patient 
determines the subsequent course of the disease and its complications. 

Treatment. Constitutional Treatment. — The patient should be 
ordered to bed and kept there until the activity of this dangerous 
infection has disappeared. His bowels should be kept open with 
repeated small doses of magnesium sulphate, his diet should be 
restricted, and he should be shielded from any mental activity or 
excitement. 

A free incision of the drum membrane should be made at once 
under a general anesthetic, preferably ethyl chloride. If there is 
pus, accompanied by pain or swelling, douche the ear with saturated 
aqueous solution of boric acid (at 99 to 105 F.), preferably with 
fountain syringe under very slight pressure. The douching should 
be repeated while the patient is awake, from once every hour to three 
times a day, according to the urgency of the case and the quantity, of 
discharge. Dry wicks of sterile cotton should be kept in the ear, 
renewed before they are soaked by the discharge. For alleviat- 
ing pain, dry heat (either a hot-water bag or a hot-salt bag) may be 
applied around the ear, in addition to hot douching. Hypnotics 
and anodynes are rarely necessary. If the tympanic drainage 
becomes obstructed, the free myringotomy should be repeated. 
For the benefit of tubal drainage, nasopharyngeal treatment is 
always indicated. To aid the meatal drainage, the diseased ear 
may be rested on a pillow, shaped like a doughnut, to prevent 
painful pressure on the ear. The position to favor tubal drainage 
is resting the head on the healthy ear. When the swelling has 
disappeared and the discharge is scanty (not due to retention), 
discontinue the douching and substitute dry cleansing with absorbent 
cotton on an applicator, followed by insufflation of enough boric 
acid powder to cover the perforation, and lightly plug the meatus 
with cotton. Tympanic inflation of the ear should be performed 
daily, commencing when the active symptoms have subsided and 
ceasing only when all signs of inflammation have disappeared. 

Prognosis. The prognosis depends upon the completeness of the 

drainage, upon the virulence of the invading micro organism, and 

upon the resistance o( the patient. If the ease has continued for 

a long time without improvement) the prognosis is poor for recovery 

without complications. 

Complications and Sequela-. There is usually some impairment 
34 



530 DISEASES OF THE NOSE, THROAT AND EAR. 

of hearing following an attack of this nature. Sometimes the 
hearing is much impaired through adhesive processes or loss of 
parts. The commonest complication is the establishment of a 
chronic otorrhea. The other complications include all possible 
varieties of complications of middle-ear infection, mastoiditis, 
osteomyelitis, sinus thrombosis, meningitis, brain abscess, and 
occasionally facial and abducens nerve paralysis. These complica- 
tions usually commence with mastoiditis. 

3. Otitis Media Purulenta Chronica. — Chronic middle-ear suppura- 
tion is the suppuration of the middle-ear tract which has progressed 
beyond the primary acute or active advancing stage of otitis media 
acuta virulenta. The discharge may continue for any length of 
time without interruption, or the ear may discharge at irregular 
intervals. 

Etiology. — Chronic middle-ear suppuration is one of the sequelae 
of an acute virulent inflammation of the middle ear. The chronicity 
of the suppuration is the result of imperfect drainage. 

Pathology. — Characteristics of this chronic suppuration of the 
middle-ear tract are ulceration of the mucous membrane, necrosis, 
loss of tissue and formation of granulomata, accumulation of 
desquamated epithelium and pus, formation of cholesteatomata, 
adhesions, and cicatricial contractions. 

Symptomatology. — The symptoms are entirely objective, being 
those dependent upon suppuration, either obvious or concealed. 
The concealed suppuration is detected by an intratympanic explora- 
tion, performed with middle-ear applicator, curette, and probe. 
The appearances are very variable, depending upon the pathological 
changes that have taken place, upon the character and amount of 
the discharge, upon the location of the focus of the inflammation, and 
upon the location and extent of the loss of tissue. The appearances 
indicate the present condition of the process and its future course. 
By the seat of the perforation and the nature of the inflammatory 
reaction, they indicate the location of the focus of infection and the 
grade of inflammation. The odor and consistency of the discharge 
are to be noted, since they give some hint to the nature of the infec- 
tion and the activity of the resistance. The consistency of the 
discharge, by the proportionate amount of serum, pus, and mucus, 
indicates the inflammatory process to be in the advancing, resisting, 
or resolving stage. The presence or absence of tympanic contents, 



DISEASES OF THE MIDDLE EAR. 53 1 

and changes in the bony wall of the tympanum, should also be 
observed. 

Diagnosis. — The presence of the suppuration, with the history 
of chronicity and the absence of acute symptoms, determines the 
diagnosis. 

Course. — The course of the suppuration may be one of four: 
subacute, chronic, perennial, or recurring. The first two courses 
may cease spontaneously without treatment or they may develop 
into one of the latter two. When the third and fourth are established 
they tend to continue indefinitely without change. Relapses of 
the acute virulent inflammation may occur at any time, especially 
in subacute and chronic cases. 

Treatment. — Success in the treatment of. chronic middle-ear 
suppuration depends not so much upon scientific knowledge and the 
drugs employed, as upon the technical skill and judgment with 
which the remedies are applied. Treatment is directed to the 
establishment of local drainage, to the removal of pathological 
accumulations and growths, and to the reduction of local inflamma- 
tion. The establishment of local drainage sometimes requires 
extensive incision of the drum membrane and cicatrices. Choles- 
teatoma and polypi must be removed. Large polypi should be 
removed with biting forceps, while smaller ones may be neglected. 
Cholesteatoma and inspissated pus should be wiped out with cotton 
pledgets when possible; if they cannot be removed dry, an intra- 
tympanic syringe with a saturated solution of bicarbonate of soda 
should be employed. After drainage has been established and 
the pathological products removed, the inflammation must be 
allayed. This is preferably done by dry swabbing, by the applica- 
tion of lotions or soothing antiseptic agents, such as alcohol, or by 
the insufflation of powders, such as boric acid. Use no stronger 
solutions than the tissues can stand without reaction. If access 
to the seat of infection is difficult, these remedies are to be used 
through a tympanic syringe or powder blower. The remedies com- 
monly used are described in Chapter XXXVII. 

Drainage should be established through the pharyngeal tube. 
In order to do this, the nasopharynx should be treated for the bene- 
fit of the tubal drainage. The state of the general health is important 
and should receive careful attention, in order to fortify the local and 
constitutional resistance of the patient. In complicated cases a 



53 2; DISEASES -OF THE NOSE, THROAT AND EAR. 

complete mastoid operation is required, sometimes only a modified 
radical mastoid operation, and very rarely an ordinary radical 
operation. 

Prognosis. — In all cases the prognosis for the cessation of the 
suppuration and for improvement in the hearing is good. The 
prognosis for rapid recovery is best in the perennial and recurring 
types; recovery in the subacute or chronic types is much slower. 
Certain conditions, such as bone caries of the ossicles and tympanum, 
localized inflammation of the epitympanum and Prussack's space, 
and of the fundus of the antrum or mastoid cells, tend to render the 
course of treatment more prolonged. 

Complications and Sequela. — Sequelae are impairment in hearing, 
slight or considerable, and occasionally persistent tinnitus. Com- 
plications are stricture of the canal, peripheral stricture of the 
Eustachian tube, granulations, polypi, necrosis and loss of drum 
membrane and ossicles, cholesteatoma, caries and necrosis of the 
temporal bone, cicatricial deformities and cicatricial reproductions 
of the drum membrane, facial and abducens nerve paralysis, 
mastoiditis, meningitis, sinus thrombosis, brain abscess, labyrinthine 
suppuration, toxemia, and bacteriemia. 

Both acute and chronic suppuration may interfere greatly with 
the hearing through loss of parts and swelling or thickening of tissue; 
and after the cessation of suppuration, by a fibrosis tympanica and 
sclerostenosis tympanica. 

OTITIS MEDIA TUBERCULOSA. 

Etiology. — Middle-ear inflammation is often an accompaniment 
of pulmonary tuberculosis, and may be the first symptom of the 
tuberculous infection. 

Pathology. — It does not seem probable that the middle ear is 
often the seat of tubercles, but rather that the middle-ear condi- 
tion is due to the edematous condition of the mucous membrane 
in pulmonary tuberculosis extending from the nasopharynx. 

Symptomatology. — The symptoms are slowly progressing cold 
seromucous or seropurulent, or cold purulent inflammation of the 
middle ear, with slow erosion of tissues, not affected by usual 
treatment. Tinnitus often annoying. Tubercle bacilli are rarely 
found in the ear discharge. 



OTITIS MEDIA LUETICA. 533 

Diagnosis. — The diagnosis is positive when there is a history 
of resistant, slow, progressive ulcerative process of the middle ear, 
with slight local reaction. The differential diagnosis between 
otitis media tuberculosa and otitis media luetica is made on the 
basis of the history and appearances. The tuberculous otitis 
media is of an asthenic type with paler surfaces, cleaner ulcerations 
and thinner, less fetid discharge. In the otitis media tuberculosa 
there is a wasting away of the tissues, whereas in the syphilitic 
condition there is thickening and swelling of the tissues. 
, Course. — The course is gradually progressive, with an unfavorable 
effect on the systemic condition, which in turn reacts on the aural 
condition. 

Treatment. — General systemic antitubercular treatment is indi- 
cated. Local treatment for the ear is directed to cleanliness with 
an attempt to prevent maceration — syringing should therefore never 
be used. Dry treatment is always indicated. The author has had 
the best results with pyoktanin blue and boric acid, equal parts, for 
a dusting powder. The nasopharynx requires local treatment to 
reduce the swelling of the Eustachian tubes. 

Prognosis. — The prognosis is good for local improvement, the 
final result depending upon the general condition and upon the 
condition of any local bone tuberculosis. 

Sequela and Complications. — The process may extend, causing 
tubercular and carious involvement of the temporal bone, with 
various intracranial and systemic complications. 

OTITIS MEDIA LUETICA. 

Symptomatology.— At first there is much swelling of the mucous 
membrane, with seromucous exudate; the tissues break down 
and suppurate, causing a rough, dirty surface and foul discharge. 
Typical glandular nodes are found in the neighborhood of the ear. 
often associated with syphilitic lesions in the nasopharynx. The 
inflammation may be of gummatous character of the type of mucous 
plaques. 

Treatment. — The treatment required is antisyphilitic constitu- 
tional treatment, with local antiseptic cleansing and stimulating 
applications of nitrate of silver. Calomel should be used as a 
dusting powder. The nasopharynx also requires attention. 



534 DISEASES OF THE NOSE, THROAT AND EAR. 

in order to prevent stenosis of the tube and to enforce tympanic 
drainage. The course of the ear lesion under the usual cleansing 
and antiseptic treatment is negative. 

Course. — There may be a rapid breaking down of the tissues, 
or the progress may be slow and accompanied by foul, dirty discharge. 

Prognosis. — The prognosis is bad, without treatment; with treat- 
ment, excellent for rapid recovery. 

Sequelce and Complications. — Possible partial or total loss of 
hearing from tympanic destruction and involvement of the labyrinth 
or more serious intracranial complications. 

Treatment of Resultant Tympanic Deformities. — The treatment 
of the tympanic deformities resulting from suppurative otitis is 
directed to removing the defect, to loosening adhesions, and to 
substituting lost parts. If there is no perforation of the tympanic 
membrane, adhesions of the drum membrane and hammer handle 
to the other structures are best managed by very forcible catheteriza- 
tion, not sufficient to rupture or relax the membrane or to cause 
any accumulation of irritation. Politzer plugs are also of great 
assistance in restoring the drum membrane to its normal position. 
When the tympanic membrane is perforated, it is desirable to close 
the perforation as soon as possible. In most cases, a disk of thin, 
sized paper, moistened and applied over the perforation, is enough 
to stimulate cicatricial repair. If this is not enough, the edges of the 
perforation can be roughened by scraping with a sharp curette 
or touched with acetic acid. When the anvil and stapes are exposed, 
the hearing can be improved by applying a disk of thin paper on 
the head of the stapes, or an artificial drum membrane, made of a 
small pledget of absorbent cotton, soaked in vaseline. In the cases 
where the stapes has been lost, the small pledget of cotton, when 
properly adjusted, will improve the hearing markedly. The artificial 
membrane should be applied over the promontory and windows. 
Individual cases demand special adjustment of artificial membranes. 

II. Trophopathia tympanica includes what has been called 
chronic middle-ear catarrh and otosclerosis, and also tympanic 
atrophy following purulent otitis media. The treatment demanded 
by this branch of otology is much more difficult than the treatment 
of suppurative diseases of the ear, and it is more important because 
of the larger number of sufferers from this group of affections, and 
because of the amount of human energy wasted through incapacity 



OTITIS MEDIA LUETICA. 535 

resulting from these diseases. Otology has acquired much disrepute 
through incompetent management of chronic catarrhal and sclerotic 
conditions. 

Under the head Trophopathia Tympanica are classified the 
following diseases of the middle ear which have no signs of active 
inflammation, but which, nevertheless, are not in a stationary 
condition, tending rather to progressively decreasing hearing. 
They have in common the symptoms of impeded middle-ear sound 
transmission, shown by increased bone- and decreased air- 
conduction, contraction of the tone field, and the symptom called 
paracusis of Willis, which indicates rigidity of the sound-transmitting 
mechanism. Under Trophopathia Tympanica are two divisions: 
1. Middle-ear conditions consequent on otitis media, including: 
a. fibrosis tympanica, b. sclerostenosis tympanica; 2. middle-ear 
conditions consequent on vasomotor changes: a. hypertrophia 
tympanica, or hyperemia tympanica chronica, and b. sclerosis 
tympanica, or anaemia tympanica chronica. These four forms 
of middle-ear disease rarely occur separately, several of them being 
usually combined in the same tympanum, different parts of the 
tympanum undergoing different changes simultaneously. 

1. Middle-ear Conditions Consequent on Otitis Media. — Fibrosis 
tympanica and sclerostenosis tympanica include the cases of middle- 
ear disease which are characterized by thickening of the mucous 
membrane, by infiltration of the submucous layer of connective 
tissue, and by the formation of adhesive bands connecting the 
tympanic contents resulting from otitis media. These conditions 
of the middle ear are without any active inflammation. The cases 
are characterized by thickening contraction, rigidity, and atrophy 
of the mucous membranes and submucous layer without any active 
inflammation, but following a previous inflammatory condition. 

a. Fibrosis tympanica is of inflammatory origin and is character- 
ized by a thickening of the mucous and submucous layers. 

Etiology.— Fibrosis tympanica is caused by an antecedent inflam- 
matory condition of any grade, which occurred in the tube and 
tympanic cavity, and which resulted in cellular infiltration and 
in a proliferation of blood-vessels. 

Pathology.— Congestion, infiltration, and proliferation of the 
submucous layer are characteristic of this condition. 

Symptomatology. —The drum membrane shows some thickening, 



536 DISEASES OF THE NOSE, THROAT AND EAR. 

opacity, retraction, and contraction. The handle of the hammer 
may be movable or rigid. The Eustachian tube is more or less 
obstructed. Beyond the appearances, the symptoms are wholly 
subjective, and consist in impaired hearing, tinnitus, and auditory 
paresthesia. Hearing tests indicate middle-ear lesion by increased 
bone conduction. The tone field is contracted, chiefly at the lower 
limit. The tinnitus is of low pitch, and the paresthesia is a drawing 
or full feeling about the ear. 

Diagnosis. — The diagnosis depends upon the thickened opaque 
drum membrane and occluded tube, and the absence of active 
inflammation. The differential diagnosis from the other forms of 
trophopathia tympanica is made on the history and evidence of 
antecedent inflammation and the presence of the above symptoms. 
The differential diagnosis from otitis media nita is made on the 
absence of exudation and swelling. 

Course. — The disease may remain stationary for an indefinite 
period. It may tend to partial or complete recovery if the functions 
of the Eustachian tubes are restored, or it may gradually progress. It 
is self-limited. If it has not already resolved after an indefinite time, 
it will assume the atrophic form termed sclerostenosis tympanica. 

Treatment. — The most important part of the treatment is naso- 
pharyngeal treatment which is especially directed to the tube. 
Forcible inflation with Politzer's air douche or with a catheter should 
be continued until the membrane is restored to its normal position 
or until there are apparent signs of commencing relaxation. These 
signs are bulging of. the upper posterior quadrant of the membrane 
on, inflation and the appearance of a supernumerary light reflex. 
Politzer's plugs are a great help in restoring the membrane to its 
normal position. 

Prognosis. — The prognosis is good for a cessation of the tinnitus 
and considerable improvement in hearing. 

Sequelce, arid Complications. — The sequel to be feared is the change 
to sclerostenosis tympanica, the atrophic form. The complication 
to be feared is the intercurrence of acute virulent infection. 

b. Sclerostenosis tympanica is of inflammatory origin, and is 
characterized by atrophy and contraction of the increased connec- 
tive tissue of the mucous and submucous layers of 4he antecedent 
fibrosis tympanica. 

■Etiology.— -The cause of this type of middle-ear disease is the 



OTITIS MEDIA LUETICA.. 537 

contraction of the fibrous tissue, in an antecedent fibrosis tympan- 
ica. With atrophy following the compression of blood-vessels 
and diminished blood supply, there is apparently some hereditary 
predisposition. 

Pathology. — A shrinkage, atrophy, and sclerosing of the infiltrated 
proliferated connective tissue of the mucous membrane and sub- 
mucous layer with diminished blood supply are characteristics of 
this condition. 

Symptomatology. — A normal or slightly thinned drum membrane, 
sometimes with calcified areas, is found. The Eustachian tube 
is normal or somewhat occluded, and the malleus movable or rigid. 
Other symptoms are similar to those of fibrosis tympanica except 
that the tinnitus is of a higher pitch and more varied, the tone 
field more contracted in the upper limit, and the hearing distance 
more reduced. 

Diagnosis. —Diagnosis is made on the appearance of a normal 
or somewhat thin drum membrane, with hearing tests indicating a 
diminution of middle-ear sound conduction — that is, increased bone 
conduction and a proportionately extensive loss of lOw tone percep- 
tion. The differential diagnosis from the other forms of tropho- 
pathia tympanica is made on the history and evidence of an ante- 
cedent inflammatory condition, and the presence of atrophy and 
degeneration shown by thinning of the tympanic membrane, calci- 
fication, etc. 

Course. — The disease may remain stationary for an indefinite 
period; it may tend to partial recovery if the functions of the 
Eustachian tube are restored, or it may gradually progress to almost 
total deafness. 

Treatment. — Inflation is usually contraindicated and must be 
used with caution in order not to cause relaxation of the membrane. 
The tympanic circulation is to be stimulated by constitutional 
tonics and by local massage. The nasopharynx requires attention 
for the benefit of the Eustachian tube. Astringent stimulation of 
the nasopharynx has a satisfactory alterative effect on the middle- 
ear atrophy. 

Prognosis. — Without treatment, the prognosis has been indicated 
under course. With treatment, the prognosis is good for improve- 
ment in hearing and for the relief of tinnitus, in inverse proportion 
to the loss of hearing when treatment was commenced. 



538 . DISEASES OF THE NOSE, THROAT AND EAR. 

Sequela, and Complications. — The complication to be feared is 
possible involvement of the labyrinth, due to the extension of the 
atrophic condition to that organ. 

2. Trophopathia Tympanica Resulting from Vasomotor Changes. — 
Hypertrophia tympanica and sclerosis tympanica are the forms of 
trophopathia tympanica, of vasomotor origin, and are not dependent 
upon previous tympanic inflammations. The tympanum may be 
affected by congestion or anemia, of vasomotor origin, due to 
constitutional, to nasopharyngeal, or other reflex causes, and to 
toxic disturbances of the sympathetic ganglia. These circulatory 
disturbances interfere with the hearing temporarily, but yield to 
general constitutional and nasopharyngeal treatment. If the 
disturbed circulation persists, it tends to develop one of these forms 
of trophopathia tympanica. 

a. Hypertrophia tympanica is of vasomotor origin and is 
characterized by congestion, infiltration, and thickening of the 
mucous and submucous layers. 

Etiology. — The primary factor is a vasomotor paresis which 
causes dilatation of the vessels and congestion. The paresis origi- 
nates from deficiency or exhaustion of the sympathetic ganglion 
and is of toxic or sympathetic origin. 

Pathology. — The congestion caused by the vasomotor paresis is 
followed by round-cell infiltration, proliferation of blood-vessels, 
and increased connective-tissue formation. 

Symptomatology. — The drum membrane shows some thickening 
and opacity, and sometimes retraction. The hammer handle, the 
promontory, and the inner end of the external auditory meatus often 
show congestion indicated by the blue color or pink flush seen 
through the membrane. Besides the appearances, the symptoms 
are wholly subjective and consist in impaired hearing, tinnitus, 
and paresthesia. Hearing tests indicate middle-ear lesion by 
increased bone conduction, The tone field is contracted chiefly 
at the lower limit. The tinnitus is of low pitch, and the paresthesia 
is a drawing or full feeling about the ear. 

Diagnosis. — The diagnosis depends upon the presence of 
chronic congestion and thickening of the mucosa, of the drum 
cavity and tube, and upon the absence of active inflammation. 
Differential diagnosis from trophopathia tympanica of inflam- 
matory origin, hypertrophic and plastic, is made on the absence 



OTITIS MEDIA LUET1CA. 539 

of inflammatory history or evidence of antecedent inflammatory 
conditions. 

Course. — The disease may remain stationary for an indefinite 
period, it may tend to partial or almost total recovery if the function 
of the Eustachian tube is restored and the vasomotor tone re- 
established, or it may gradually progress. It is self-limited. If 
it continues to progress, it will, after an indefinite period, become 
atrophic from contraction of the new fibrous tissues and shutting off 
of the blood-vessels, and develop into sclerosis tympanica. 

Treatment. — Treatment is especially directed to restoration of 
the vasomotor tone by building up the general system and relieving 
toxic causes of sympathetic ganglia paresis, chiefly to be found in the 
nose and pharynx. 

Prognosis. — Prognosis is good for arrest of the diseased condition, 
reduction of tinnitus, and for considerable improvement in hearing. 

Sequela and Complications. — Sequelae to be feared are the change 
to sclerosis tympanica, the atrophic and contracting form of tropho- 
pathia tympanica. Complications to be feared are acute virulent 
infections. 

b. Sclerosis tympanica is of vasomotor origin and is characterized 
by atrophy and contraction of the connective tissue of the mucous 
and submucous layers, and by anemia. 

Etiology. — This condition is due to vasomotor disturbances which 
may or may not have caused an antecedent congestive condition, 
hypertrophia tympanica, but which may have caused primary 
anemic and consequent atrophic changes. There is considerable 
hereditary predisposition to this affection. Frequently there is a 
nervous shock which acts as an exciting cause. 

Pathology. — The characteristics of sclerosis tympanica are 
contraction, anemia, and atrophy of the tympanic mucous membrane 
and submucous layers. 

Symptomatology. — Objective symptoms. Normal or slightly 
thinned drum membrane, sometimes with calcified areas; Eusta- 
chian tube normally or abnormally patulous or somewhat occluded; 
malleus movable or rigid. The subjective symptoms are similar 
to those of the previous group, with this difference that the tinnitus 
is of a higher pitch and more varied, the tone field is more contracted 
in the upper limit, and the hearing more reduced. 

Diagnosis.— Diagnosis is made on the appearance of a normal. 



54-0 DISEASES OF THE NOSE, THROAT AND EAR. 

calcified, or somewhat thinned drum membrane, with hearing 
tests indicating a diminution of middle-ear sound conduction. 
Differential diagnosis from sclerostenosis tympanica of inflammatory 
origin is made on the absence of history or evidence of a preexisting 
inflammatory condition. 

Course. — The disease may remain stationary for an indefinite 
period, it may tend to partial recovery if the functions of the vaso- 
motors are restored, or it may gradually progress almost to total 
deafness. 

Treatment. — Treatment is directed to the nasopharynx, as in 
the previous condition. Tympanic inflation is usually contra- 
indicated. Stimulation of the vasomotor functions is imperative. 
This is brought about by constitutional tonic treatment, naso- 
pharyngeal treatment directed to antisepsis and stimulation, and 
hygiene with local stimulation by massage, rubefacients and 
electricity. 

Prognosis. — Without treatment, the prognosis has been indicated 
under course. With treatment, the prognosis is good for improve- 
ment in hearing and tinnitus in inverse proportion to the loss of 
hearing when treatment was commenced. 

Sequelce and Complications. — The complication to be feared is 
possible involvement of the labyrinth, due to extension of the atrophic 
condition to that organ. 

AUTHOR'S BIBLIOGRAPHY. 

Treatment of Chronic Purulent Otitis Media with Illustrative Cases. Med. 

Trans, of State of N. Y., Albany, 1905, pp. 347-350. 
The Management of Suppuration of the Middle Ear, Based on an Analysis of 

100 Consecutive Cases Seen in Private Practice. The Laryngoscope, 

St. Louis, March, 1908, vol. xviii, No. 3, pp. 193-206. 
Cleansing Treatment of Chronic Suppuration of the Middle Ear. Jour, of 

the Am. Med. Asso., Chicago, Sept. 14, 1907, vol. xliv, pp. 926-929. 
Perforation of Shrapnell's- Membrane. Caries of the Malleus. Purulent 

Discharge. Trans, of the Amer. Otol. Soc, Xew Bedford, 1905, vol. 

ix, pt. 1, pp. 129-32. 
.Middle-ear Sclerosis or Atrophic Middle-ear Catarrh. Jour. Am. Med. 

Assoc, Chicago, August 1, 1908, vol. li, No. 5, pp. 364-366. 
The Value of the Present Qualitative Tests of Hearing, with Demonstrations 

of a New Apparatus. Med. Record, N. Y., vol. lxvii, 1905, p. 489. 
Collodion: Its Use when the Membrana Tympani and Malleal Ligaments 

are Relaxed. Ann. of Otol., Rhin. and Laryn., St. Louis, June, 1905, 



AUTHOR S BIBLIOGRAPHY. 541 

vol. xiv, No. 2, pp. 283-88. Trans, of the Amer. Otol. Soc, New Bed- 
ford, vol. ix, 1905, pt. 1, pp. 23-31. 
Otosclerosis Treatment, Annals of Otol., Laryn. and Rhin., 1909. 
The Preventive and Abortive Treatment of Mastoiditis. The Post-Graduate, 

New York, Nov., 1906, vol. xxi, No. 11, pp. 1071, 1076. 
A Phonographic Acoumeter. Archiv. of Otol, New York, vol. xxx, 1904, p. 438. 
Middle-ear Suppuration. New York Medical Journal, Oct. 17, 1908, vol. 

lxxxviii, No. 16, pp. 727-732. 
Chronic Interstitial Otitis or Chronic Middle-ear Catarrh and Otosclerosis. 

Laryngoscope, St. Louis, 1909. 
Chronic Middle-ear Deafness. Jour. Laryn., Rhin. and Otol., London, vol. 

xxiii, 1908. 
Stricture of the Eustachian Tube in Aural Diseases. Annals of Otol., Rhin., 

and Laryn., St. Louis, 1905, vol. xiv, pp. 274-283. 
Aural Inspections and Functional Tests in Healthy Individuals. A Plea for 

the Prevention of Deafness. Ann. of Otol., Rhin. and Laryn., St.-- 

Louis, vol. xvi, No. 2, June, 1907, pp. 374-379. 
Short and Easy Methods of Arriving at Good Results in Common Diseases of 

the Ear and Upper Air Tract, Illustrated by Recent Cases. Annales 

del Quarto Congreso Medico Pan-Americano, Havana, 1906, vol. ii, pp. 

191-206. 
The Treatment of Tinnitus Aurium. The Laryngoscope, St. Louis, July, 

1904, vol. xiv, No. 7, pp. 531-541. 
Two Cases of Otitis Media Catarrhalis Chronica, Showing Improved Hearing 

after Acute Mastoiditis, Treated by Operation. Trans, of 13th Ann. 

Meeting of Am. Laryn., Rhin. and Otol. Soc, 1907, p. 313. 



CHAPTER XXXII. 

DISEASES OF THE SOUND-PERCEIVING APPARATUS. 

Anemia of the cochlea, a condition found in persons of feeble 
circulation, is a common cause of deficient hearing in debilitated 
individuals. Anemia of the cochlea sometimes accompanies 
mental or physical shock. Since the deafness is relieved when the 
circulation improves with the general condition, no special manage- 
ment of this condition is required. The diagnosis is made on a 
negative physical examination of the ear, showing normal range 
of tone perception, diminished distance and time perception, and 
loss of bone conduction. In this condition the symptoms are 
similar to those of presbyacusis, except that tinnitus is often present. 

Hyperemia of the cochlea is generally associated with hyperemia 
of the neighboring organs. Like anemia of the cochlea, this 
condition is managed by general methods directed to the relief 
of congestion, such as phlebotomy, purgatives, diaphoretics, and 
emetics in acute cases, and general hygienic measures in the chronic 
cases. The diagnosis is made on the physical examination of the 
ear, which shows some congestion of the external meatus, tympanic 
membrane, and promontory, but no inflammatory symptoms. 
Functional tests are apt to be variable. The tone field is usually 
contracted. Tinnitus often accompanies this condition. 

Hemorrhage in the cochlea is usually associated with arterial 
degeneration or increased arterial tension. The cause is usually 
weakness of the vascular walls, but it may be trauma from a loud 
sound or explosion, or concussion of the ear. The symptoms 
are of sudden onset, ushered in either by an apopleptic attack or 
upon the occurrence of the trauma. Loss of hearing is usually total, 
or only a small amount of air conduction remains. Tinnitus is 
sometimes extremely loud and usually of high pitch. The tone 
field is very much contracted, especially at the upper limit. The 
treatment indicated is absolute rest of the organ. If the cause is a 
vascular one, the circulatory system requires the ordinary treat- 
ment under such a condition. The use of iodides in increasing 

542 



COCHLEITIS. 543 

doses is indicated. The treatment should be continued for several 
weeks or months, according to the progress made. The prognosis 
is unfavorable for total recovery. The amount of recovery is in 
inverse proportion to the extent of the injury and to the recuperative 
power of the patient. 

Spongification of the Labyrinth Capsule or Otosclerosis, — The 
etiology and pathology of this condition is the same as that when 
the middle-ear mechanism alone is affected by the atrophic process, 
except that in this condition we have hyperostosis and rarefaction 
of the labyrinthine capsule and involvement in the cochlea. The 
condition may show itself first by cochlear symptoms or by middle- 
ear symptoms. These cochlear symptoms are the classical signs 
of inner-ear deafness, contraction of the auditory field, especially 
at the upper limit, decreased bone conduction, decreased distance 
and time hearing and marked tinnitus. Diagnosis is extremely 
difficult unless there are also symptoms of the middle-ear affections, 
sclerosis or sclerostenosis tympanica, which include otosclerosis. 
(For treatment, see Middle-Ear Diseases.) 

COCHLEITIS. 

PURULENT INFLAMMATION OF THE COCHLEA. 

Etiology. — Pyogenic infections, involving the cochlea from the 
middle ear, usually pass through the external semicircular canal 
and vestibule. Occasionally the infections enter through the oval 
or round windows or through the promontorial wall. Very rarely 
the infection has a central origin and passes outward through the 
internal auditory meatus or aqueducts into the cochlea. 

Course. — The course is often progressive, with a tendency to 
invade neighboring structures. Consequently dangerous complica- 
tions, such as meningitis, or brain abscess, may arise from extension. 
The process is sometimes circumscribed and self-limited. The 
destruction may include any part of, or the entire cochlea, which 
in young patients may come away as a sequestrum. Under those 
circumstances, products of the inflammation are discharged into 
the middle ear. 

Symptoms. — The symptoms are of two kinds: 1. septic symptoms, 
which depend for their severity upon the amount of constitutional 
absorption of toxins, which may be slight or extreme; and 2. sensory 



544 DISEASES OF THE NOSE, THROAT AND EAR. 

symptoms, either total deafness or great loss of hearing and bone 
conduction. 

Diagnosis. — The diagnosis is made on the presence of febrile 
reaction and sudden loss of hearing, which is out of proportion to 
the middle-ear conditions present. 

Treatment. — The treatment may be expectant or operative. The 
expectant treatment is similar to that for middle-ear suppuration; 
the operative treatment is described in the chapter on Operations on 
the Labyrinth. 

Prognosis. — With an early operation the prognosis indicates 
partial or total loss of hearing. Without operation, the prognosis 
is bad for recovery, on account of the danger of intracranial extension. 

Syphilitic cochleitis shows characteristic specific nerve and bone 
lesions. 

Course. — The course is usually progressive to total deafness. 

Symptoms. — The symptoms are the classical signs of progressive 
cochlear deafness, and tinnitus, associated with the signs of the 
history of luetic disease. There is loss of air conduction and a 
contracted auditory field. 

Diagnosis. — -The diagnosis is made on the symptoms of a pro- 
gressive cochlear affection with corroborative symptoms of syphilis. 

Treatment. — Treatment is constitutional antisyphilitic and should 
be pushed to the limit of the patient's physiological endurance. 

Prognosis. — Without treatment there is gradual decrease of hearing; 
with treatment, except in very advanced cases the prognosis is good 
for improvement, and in early cases it is good for total recovery. 

Cochleitis as a Frequent Complication of Cerebrospinal Meningitis. — 
This disease may attack the cochlea by extension from the middle 
ear, or it may extend from the meninges. The disease usually 
progresses to entire destruction of hearing. The symptoms are 
great impairment of the cochlear organ, and usually absolute deaf- 
ness. The diagnosis is made on the impaired cochlear function in 
connection with epidemic cerebrospinal meningitis. The treat- 
ment is directed to the primary affection and also to the absorption 
of the products of inflammation by the use of iodides. If laby- 
rinthine suppuration is present, treatment is directed to this 
condition. 

Cochleitis as a complication of influenza is indicated by loss of 
cochlear hearing in connection with or following the influenzal 



cochleitis. 545 

infection. The inflammation of the cochlea does not often develop 
into suppuration, but complete restoration of hearing is not to be 
expected. The treatment in the acute stage is the same as that 
required by the general infection. In the subacute and chronic 
conditions, general constitutional treatment and the administration 
of iodides is indicated. If suppuration occurs, surgical intervention 
is required. 

Cochleitis is a well-recognized complication of parotitis or mumps. 
No special treatment is known for this complication other than 
that given in a case of resolving cochleitis, i.e., total functional rest, 
constitutional hygiene, and the use of iodides. It is as important 
to protect an inflamed auditory organ from severe stimulation by 
noise as it is to protect an inflamed eye from light. The prognosis 
is bad for total recovery. There is, however, generally marked 
improvement in the hearing. 

Affections of the Cochlear Nerve Fibers. — Such affections are 
indicated by diminished hearing, decreased or absent bone conduc- 
tion, loss of high notes and slow auditory reaction, giving symptoms 
of paresis or paralysis of the auditory nerve. The pathological 
conditions are perineuritis, interstitial neuritis, degeneration of 
ganglion cells and degeneration of nerve fibers. The nerve lesions 
may follow functional traumatism, pyogenic bacterial infection, 
pressure of tumors, epidemic cerebrospinal meningitis, ptomaine 
poisoning, mumps, influenza, syphilis, and the ingestion of certain 
drugs — quinine, salicylates, and wormseed oil. Treatment consists 
in absolute functional rest, full dose of strychnine by the mouth 
after the acute stage has subsided, and the use of iodide of potassium 
in the later stages to relieve the pressure from circulation in inflam- 
matory cases. 

The function of the cochlea is impaired to a marked degree by 
want of use over long periods, as is shown by the effect of long 
closure of the canal in ah otherwise normal ear. The impairment 
of one ear acts through the association and decussation of the 
cochlear nerve fibers as a cause of impaired central and nerve 
hearing in the otherwise non-affected ear. 

Cerebral Deafness. — The symptoms of cerebral deafness are 

similar to the preceding nerve deafness, with the additional symptom 

of retarded central reaction. The causes of the central deafness 

are local inflammatory or degenerative conditions of the auditory 

35 



546 DISEASES OF THE NOSE, THROAT AND EAR. 

tract or centers, tabes, poliomyelitis, and new growths. There 
are certain characteristic symptoms which give definite location to 
some of the lesions. The combination of the vertiginous and 
auditory symptoms locate the lesion where the cochlear and vestibular 
nerves are associated. The absence of the vertiginous symptoms 
and the presence of aphasic symptoms locate the lesion in the 
higher centers of the auditory sphere. The differential diagnosis 
between the inflammatory and the tumor or pressure conditions 
is made on the presence or absence of inflammatory signs. The 
treatment for the inflammatory conditions is removal of the cause, 
if possible, careful hygiene, and functional rest; for the tumor 
conditions, treatment is surgical removal of the tumor unless it be 
of luetic origin, in which case specific antisyphilitic treatment is 
indicated. 

Deaf-mutism is dependent on defect of the sound-perceiving 
apparatus, which may be congenital or acquired at an early age 
before the habit of speech is established. 

Etiology. — i. Congenital deaf-mutism is due to an absence 
or malformation of the sound-perceiving apparatus; 2. acquired 
deaf-mutism is due to lesions of the sound-perceiving apparatus, with 
or without lesions of the middle and outer ears. The defects must 
have arisen before the mechanism of speech was fully developed. 

Pathology. — The congenital form is extremely rare. It is due 
to gross defect of the labyrinth, usually associated with absence 
of the middle ear and arrested development of the auditory nerve. 
The acquired form may be divided into the central and the peripheral. 
The central forms are the more common and are due to auditory 
neuritis of toxic or inflammatory origin. The toxic variety is due 
to poliomyelitis, ptomaine poisoning, and in rare cases to drug 
poisoning. The inflammatory variety is due to epidemic cerebro- 
spinal meningitis, measles, or scarlet fever. The peripheral form 
is due to inflammatory conditions originating in the middle ear, 
such as complications of measles, scarlet fever, and other fevers. 
Otitis media suppurativa in early life may cause deaf-mutism. 
The labyrinthine degenerations in this group are due to disuse 
except when there has been cochleitis. 

Diagnosis. — The diagnosis is made independent of age if consider- 
able deafness is present before speech has developed. The deter- 
mination of deafness in young children is more difficult than in 



cochleitis. 547 

adults. To determine the degree of deafness, the voice test should 
first be used by a member of the family. The child should be turned 
away and its attention absorbed by a third person, while the person 
making the test approaches from behind at a distance and calls 
to the child. If the child does not respond before the impact of the 
sound can be felt or the tremor of the approaching footsteps per- 
ceived, the child is very deaf. The next point is to establish the 
practical absence of hearing. This is best done by striking a gong 
or glass bowl at a short distace behind the preoccupied child. 
If the child does not turn immediately toward the source of sound, 
it is practically absolutely deaf. 

Treatment. — The treatment is directed to improving the middle- 
ear conditions, with special attention to adenoids and nasopharyn- 
geal obstruction, and to middle-ear inflation, if the membranes are 
depressed. The use of iodides is indicated for the benefit of the 
sound-perceiving apparatus. 

Prognosis. — In a few cases classed as deaf-mutes, sufficient 
hearing has been restored by appropriate treatment to enable the 
children to advance in the usual way. Under favorable conditions 
— that is, with totally deaf-mute children of good mentality who 
receive constant individual care from an early age — the results of 
education will be good for comprehension of language, and in some 
cases for intelligible speech. There are on record a few cases of 
superior mental development in educated deaf mutes. Laura 
Bridgman and Helen Keller are examples of blind deaf-mute 
geniuses. 

Education. — The education of deaf children who have never 
spoken should begin as soon as possible, not later than the seventh 
year. With children who have acquired the use of some words, 
every effort should be made at once to retain these words, since the 
difficulty of acquiring the use of language under these conditions 
is insignificant compared with the difficulty of teaching the first 
word. The greatest aid to instruction is the tactile sense of sound 
vibration, which is always present and which can be greatly 
developed. 

Children who are backward in school are often suffering from 
deafness, and require proper aural treatment for improvement of 
hearing and instruction in special classes for their mental 
do elopment. 



548 DISEASES OF THE NOSE, THROAT AND EAR. 

AIDS TO HEARING, MECHANICAL AND ELECTRICAL. 

A great variety of acoustical mechanical devices have been 
constructed to increase the volume of sound which reaches the 
tympanum. One principle of construction is a tube with a flaring 
orifice which fits into the'external auditory meatus. The tapering 
part should be conchoidal for the best focusing and transmission of 
sound. The length of the tube and its form, whether straight or 
curved upon itself, is a matter of individual convenience. 

Patients who have very good bone conduction may have their 
hearing efficiency increased by the use of a thin sheet of some 
elastic material, such as hard rubber or even paper. The patient 
should place one end of the sheet against the teeth and bend the 
sheet so as to make it tense. It will then respond to the sound 
vibrations of air, which will be carried to the cochlea by bone 
conduction. 

The micro-telephonic devices, now in use as aids to hearing prove 
very satisfactory, especially in cases which have proportionately 
great deficiency in high tone perception. 

The general principle in selecting an aid to hearing is that the 
patient should try various hearing devices before selecting one, 
since individual peculiarities cannot always be determined without 
a practical test. 

The devices used to improve middle-ear sound transmission are 
described in the chapters on Physiopathology and Suppurative 
Middle-ear Diseases. 



DISEASES OF THE ORGAN OF EQUILIBRATION OF 
THE VESTIBULAR MECHANISM. 

Owing to the close connection of the vestibular nerve and its 
roots with the motor and sympathetic nerve tract, disturbances 
of these functions are always found with severe irritation of the 
vestibular nerve, producing circulatory, gastric, motor-ocular, 
and musculo-dynamic disturbances. The symptoms of the 
disturbance of the vestibular apparatus, are either false reaction — 
para-equilibrium, oversensitiveness — hyper-equilibrium, or loss 
of sensitiveness — hypo-equilibrium. 

Para-equilibrium. — The presence of this condition is evidenced 



DISEASES OF THE ORGAN OF EQUILIBRATION. 549 

by vertiginous symptoms which may be associated with nystagmus, 
great muscular weakness, and vomiting. These symptoms show 
irritation of the vestibular apparatus without sufficient functional 
stimulation. 

Hyper-equilibrium may be present without any active signs of 
inflammation or other irritation. This hyper-sensitiveness is 
demonstrated by causing the patient to perform some movement 
which brings the vestibular apparatus into action. The simplest 
way is to cause the patient to stand erect and rapidly turn upon his 
heels from one to four times. If he shows evidence of loss of 
equilibrium after one or two turns, hyper-sensibility is demonstrated. 
A stool with a rotary seat is very convenient for the test. 

Hypo-equilibrium. — To demonstrate the lack* of sensibility, 
the patient is told to close his eyes and stand erect, while the observer 
turns him rapidly on his heels. If there is no vertiginous reaction 
after three or four turns, the vestibular apparatus is paretic. If 
on continued rotation no vertiginous symptoms appear, the vesti- 
bular apparatus is paralyzed. 

Nystagmus. — Nystagmus is developed in the direction of the 
rotation in individuals with a normal vestibule by rapidly rotating 
the person to the right or left four or five turns. After the cessation 
of the rotation the nystagmus is reversed and occurs in the opposite 
direction to the rotation. Nystagmus is an accompaniment of 
vertigo in physiological and pathological conditions. 

Increased nystagmus is an important symptom of labyrinthine 
disease with vestibular irritation. With an irritated labyrinth the 
nystagmus is most marked toward the irritated side. With extreme 
vestibular irritation nystagmus is present without external stimula- 
tion. With a less degree of vestibular irritation and a high degree 
of latent nystagmus, the nystagmus is developed by causing the 
patient to turn the eyes toward the diseased side. In a less degree 
of vestibular irritation and a less degree of latent nystagmus, 
nystagmus is developed to an abnormal degree by rapidly rotating 
the patient several times. After rotation toward the diseased 
side, straining the eyes in the opposite direction will develop an 
exaggerated nystagmus. 

With abnormal vestibular irritability rotation toward the affected 
side develops nystagmus more quickly than with a normal vestibule; 
and, after cessation of the rotation reverse nystagmus is developed 






550 DISEASES OF THE NOSE, THROAT AND EAR. 

to a greater degree than with a normal vestibule. With a recently 
paralyzed labyrinth nystagmus is most marked toward the healthy 
side as if it were abnormally irritable. Vertiginous symptoms 
follow anomalies of intratympanic tension and change in labyrinthine 
circulation, just as tinnitus occurs in the cochlea under similar 
circumstances. Nystagmus sometimes occurs independent of 
labyrinthine disturbances. 

DISEASES OF THE LABYRINTH AS A WHOLE— THE 

INNER EAR. 

Injuries of the Inner Ear due to Heavy Detonation and Concussion. — 
Heavy detonation and concussion rupture the drum membrane 
usually in the posterior superior quadrant and also rupture the 
membrana tympani secundaria and the orbicular ligament of the 
stapes and cause severe injury to the labyrinthine structures. 

Diagnosis. — The diagnosis is made on the history of traumatism 
with evidence of a tear in the drum membrane and symptoms of 
severe labyrinth impairment. 

Treatment. — Treatment is rest in bed on light surgical diet with 
a light cotton plug in the meatus which is to be kept dry. If signs 
of infection develop, treatment is carried out as in labyrinthine and 
middle-ear infection. 

Prognosis. — The prognosis is good for speedy recovery in unin- 
fected cases with more or less permanent destruction of the func- 
tion of the labyrinth. With infection, the prognosis is grave. 

Injuries of the inner ear complicated by fracture of the base of 
the skull. The ear symptoms differ with the extent of the injury, 
the organs ruptured, the amount of the hemorrhage and the amount 
of serous leakage. The pathognomonic sign of fracture of the bone 
is the split in the inner end of the canal, usually the upper part, 
which involves part of the drum membrane. The patient may 
show nothing more than the symptoms of middle-ear injury, or he 
may have cochlear and vestibular symptoms together with symptoms 
of intracranial concussion and hemorrhage. Later, septic and 
inflammatory symptoms may be superadded. 

Treatment. — The patient is put to bed, even if there are no 
subjective symptoms. The first treatment indicated is asepsis. 
If the ear is dry it should be lightly plugged with cotton and let 



DISEASES OF THE LABYRINTH. 55 1 

alone. If the ear is moist it should be wiped dry, washed with alcohol, 
again wiped dry, and securely plugged with sterile absorbent cotton. 
The nose and pharynx should be attended to in order to promote 
tubal drainage. If the leaking of fluid continues from the ear, 
dry sterile wicks should be kept constantly in the meatus. As the 
fluid decreases, boric acid powder is insufflated into the canal. 
The meatus is kept plugged until the wound is entirely closed. 
If infection and inflammation sets in, it must be treated as otitis 
media and interna, with intracranial complications. The complica- 
tions of injury of the labyrinth are rare. 

Panotitis is the term used to denominate an infection of the inner 
and middle ears. It is characterized by the combination of middle 
ear, cochlear and vestibular symptoms, together with the constitu- 
tional symptoms of infection. The treatment is indicated by the 
extent of the disease, which requires attention first to the middle 
and inner ears, and afterward constitutional treatment. 

As has been said, the vestibular apparatus is often affected in 
connection with the cochlea, and the symptoms of the two affections 
naturally occur together. This is particularly noticeable in the 
symptom complex known as Meniere's disease, which has no 
special pathological basis. The complex is made up of vestibular 
and cochlear symptoms — vertigo, vomiting, deafness, and tinnitus. 
The whole labyrinth may be involved in a suppurative process — 
a complication most often seen in the exanthemata of childhood. 
The labyrinth has a remarkable power of limiting infection or 
poison to small areas. Part of the cochlea or part of the vestibule 
may be destroyed and thrown out as a sequestrum, without any 
injury to the remainder. 

Hyperemia and anemia of the labyrinth, with signs of disturbance 
of the cochlear and vestibular equilibratory functions are due to 
defects in the vasomotor mechanism from constitutional or naso- 
pharyngeal causes. .They quickly yield to treatment after the 
removal of the cause. 

The labyrinth may become invaded by non-suppurative disease 
originating in the middle ear. Otosclerosis affects the bone of the 
labyrinth capsule. It may continue and disturb the labyrinth, and 
especially the cochlea by exostoses impinging on the membranous 
labyrinth. The cochlear apparatus is more often disturbed by the 
pathological conditions in the nose and throat and by the extension 



552 DISEASES OF THE NOSE, THROAT AND EAR. 

in otosclerosis than is the vestibular apparatus. On the other hand, 
the peripheral organ of equilibration, or the vestibular mechanism 
and the equilibrational tract, are less susceptible to toxic injury 
or reflex disturbances than the auditory or cochlear peripheral 
organ and tract. On account of the varying susceptibility of the 
two divisions of the labyrinth, infection often reaches the vestibule 
before it does the cochlea. Invasion of the vestibule takes place 
through the external semicircular canal, which is sometimes per- 
forated as a complication of otitis media. 

The vestibular apparatus is also more often affected by constitu- 
tional disturbances, by bacterial invasion, and by irritation of the 
vagus, than is the cochlear apparatus. These facts are shown by 
the frequency of vertiginous symptoms with general disorders, and 
the frequency of infectious labyrinthitis with vestibular involvement. 
The cochlea is seldom so disturbed. 

In other respects the pathology of the auditory and equilibrational 
mechanisms is identical. 

AUTHOR'S BIBLIOGRAPHY. 

Deaf-mutism and Ptomain Poisoning. Trans, of the Amer. Otological Society, 

vol. ix, 1905, pp. 32-42. 
Capital Operations for the Cure of Tinnitus Aurium. lour, of the Amer. 

Med. Ass'n, Chicago, Dec. 9, 1905, vol. xiv, No. 24, pp. 1787-92. 
A New Instrument for Mastoid Surgery. The Laryngoscope, St. Louis, Oct., 

1905, vol. xv, No. 10, 796-801. 
Labyrinthine Syphilis. Am. Jour, of Dermatology, May, 1906, vol. x, No. 

5, pp. 192-95- 



CHAPTER XXXIV. 

THE MAJOR SURGICAL DISEASES OF THE EAR AND THEIR 

COMPLICATIONS. 

MASTOIDITIS. 

Etiology. — Mastoiditis is due to the extension of the inflammation 
of the mucous lining of the middle ear to the bony walls and cells 
of the antrum and to the mastoid cells. Occasionally the develop- 
ment of mastoiditis is due to traumatism or to direct extension of 
some external inflammation, such as lymphadenitis and otitis 
externa. 

Symptomatology. — In the order of their frequency the symptoms 
are pain, tenderness, pyrexia, rapid pulse, and swelling in the mas- 
toid region. Any of these may be lacking in certain cases, in which 
event circumstantial evidence will indicate mastoiditis. The 
circumstantial evidences of mastoiditis are febrile conditions, 
increased pulse rate, a temperature above 99 , coated tongue, loss 
of appetite, and general weakness, without any cause more probable 
than the infected ear. If a subacute or chronic purulent otitis is 
present, or if there is a history of a recent attack of otitis, these 
febrile symptoms become positive evidences of mastoiditis. 

Diagnosis. — When there is active middle-ear inflammation or 
a history of a recent otitis media, the diagnosis is made on the 
evidences of periostitis over the mastoid region, as shown by deep 
swelling, or on the evidence of periostitis in the canal, shown by 
narrowing of the canal and drooping of the posterior superior inner 
osseous wall of the canal. The diagnosis is also positive when there 
is pain which increases on deep pressure over the posterior end of 
the digastric fossa or over the mastoid antrum, and with history of 
middle-ear inflammation. If none of the above signs is present, 
but if there is a history of an aural infection followed by a persistent 
pyrexia, rapid pulse and an increased differential polymorphic 
Leucocyte count, which cannot be explained by disease of some 
other origin, a positive diagnosis of mastoiditis is made. 

553 






554 



DISEASES OF THE NOSE, THROAT AND EAR. 



The differential diagnosis from otitis externa, mastoid adenitis, 
parotiditis, and angioneurotic edema. In otitis externa there is 
tenderness and swelling of the cartilaginous auditory canal and an 
extra-periosteal swelling and tenderness. Mastoid adenitis is 
characterized by extra-periosteal swelling over the mastoid process, 
not often associated with middle-ear inflammation. The swelling 
of parotiditis is extra-periosteal, and most developed over the 
parotid glands. Angioneurotic edema fluctuates without any 
apparent local cause, and the swelling may move from place to 
place. 




Fig. 213. — Patient with mastoiditis with subperiosteal abscess, showing mastoid swell- 
ing and displacement of auricle, compared with normal side, viewed from behind. 



Prophylaxis. — The prophylaxis of mastoiditis is achieved by 
prevention of middle-ear infection, and by early and efficient treat- 
ment when the infection has taken place. 

Treatment. — If the symptoms of the mastoiditis are not far 
advanced, and there is any definite objection to operative interference, 
expectant treatment can be followed on these lines — establishment 
of free tympanic drainage through the meatus by extensive myrin- 
gotomy, saline laxatives, rest in bed, normal salt solutions by the 
mouth or rectum, artificial leeching over the mastoid process, 
douching of the auditory canal with saturated aqueous solution of 
boric acid of temperature ioo° to no° every hour, and applications 
of heat over the mastoid region. 



INFECTIOUS OTITIS INTERNA. 555 

Indications for Operation. — As soon as the presence of mastoiditis 
is definitely established, operative treatment will afford the best 
results in point of speedy recovery and restoration of hearing. 
An operation before the constitutional symptoms indicate toxemia 
or the local external signs show softening will prevent further 
complications. 

Prognosis. — If an early operation is performed, the prognosis 
is good for complete recovery in from one to three weeks with re- 
establishment of normal hearing. Without operation, the prognosis 
is for slow recovery with impaired hearing, with the development 
of serious complications in a few cases. The complications, if 
not efficiently managed, result fatally. 

Complications. — The complications of mastoiditis are subperiosteal 
abscess, osteomyelitis, labyrinthitis, epidural abscess, sinus throm- 
bosis, pachymeningitis, perisinus abscess, subdural abscess, lepto- 
meningitis, cerebrospinal meningitis, brain abscess, metastatic abscess, 
toxemia and bacteriemia. One of the most usual complications of 
mastoiditis is osteomyelitis, which is inflammation of the bone-marrow 
associated with softening of the bone. The inflammation extends 
widely through the temporal bone, and requires extensive bone 
excavation for its removal. 

INFECTIOUS OTITIS INTERNA. 

Etiology. — Infectious otitis interna is due to an extension of a 
tympanic inflammation into the labyrinth, or to an extension of 
inflammation of the meninges into the labyrinth. 

Symptomatology. — The symptoms, if the cochlea is affected, are 
rapidly increasing deafness and loss of bone conduction. If the 
vestibular apparatus is affected, the vertiginous symptoms are 
very marked. In either case, the symptoms are associated with 
indications of constitutional infection and rise of temperature. 

Diagnosis. —The diagnosis is made on the above marked symp- 
toms, in connection with either meningeal or tympanic inflammation. 

Prophylaxis.— Prophylaxis consists in the avoidance of intra- 
cranial or tympanic inflammations, or if these inflammations have 
already occurred, in their successful management. 

Treatment.— Tympanic drainage, with rest in bed and saline 
laxatives, can be tried for a short time before operative interference 



556 DISEASES OF THE NOSE, THROAT AND EAR. 

is inaugurated. A continued septic temperature with rapid pulse, 
and the above symptoms after the establishment of tympanic drainage 
or increasing gravity of the symptoms, are indications for operation. 

Prognosis. — The prognosis is for partial or total loss of function. 
In a few cases, usually in adult cases, fatal intracranial complications 
develop. After operation the intracranial complications are much 
less frequent, and the prognosis is proportionately better. 

Complications. — The complications of labyrinthitis of tympanic 
origin are intracranial inflammations, meningitis, and brain abscess. 



INTRACRANIAL COMPLICATIONS OF DISEASES OF 

THE EAR. 

PACHYMENINGITIS, EPIDURAL ABSCESS, PERISINUS ABSCESS, SUB- 
DURAL ABSCESS. 

Etiology. — Pachymeningitis, epidural abscess, perisinus abscess, 
and subdural abscess are due to the extension of infection from the 
tympanum. This infection, usually passes through the mastoid 
cells to the sigmoid groove, or more rarely through the tegmen into 
the middle fossa, or through the labyrinth into the cerebellar 
fossa. 

Symptomatology. — The symptoms are exaggerated forms of those 
present in middle-ear and mastoid inflammations. If the focus 
of the complication is in the neighborhood of the emissary vein, the 
headache and tenderness over the emissary vein are more marked 
than is usually the case with uncomplicated middle-ear and mastoid 
inflammation. If the focus is in the middle fossa the temporal head- 
ache may be extreme. 

Prophylaxis. — The prophylaxis is an early mastoid operation. 

Treatment. — The treatment is operative. The indications for 
operation have been long neglected by the time any intracranial 
complications of mastoiditis are apparent. 

Prognosis. — The prognosis is good for recovery after early 
operation, and bad for further intracranial complications without 
operation. 

Complications. — The complications are further intracranial ex- 
tension, the chief development being sinus phlebitis and thrombosis. 



turn 



SINUS PHLEBITIS. 557 



SINUS PHLEBITIS. 



Sinus phlebitis of the intracranial sinuses and veins becomes 
sinus thrombosis when the inflammation has advanced to desquama- 
tion of the endothelium, and to formation of thrombi. Sinus 
thrombosis is designated primary when the infection invades the 
sinuses directly from the infected tympanum, and secondary when 
it proceeds through the infection of the mastoid cells to the sinus. 
The sinuses primarily involved are the sigmoid, lateral, inferior 
and superior petrosal and jugular bulb. All the remaining sinuses 
and jugular vein may be involved secondarily. The cerebral veins 
are also subject to phlebitis of otitic origin. 

Etiology. — Phlebitis and thrombosis are caused by extension of 
inflammation from the tympanum and mastoid cells into the walls 
of the adjacent sinuses and veins. The phlebitis and thrombosis' ex- 
tend with and against the blood stream. 

Symptomatology.— The symptoms may be very obscure. In 
typical cases they consist in the repeated high rise and fall of the 
temperature curve, and in the presence of streptococcemia and 
metastatic abscesses. 

Diagnosis. — The diagnosis is positive upon the present or recent 
history of ear infection, with the characteristic saw-toothed tempera- 
ture curve, or upon the discovery of streptococcemia, provided, of 
course, that there is not a more obvious cause for the constitutional 
symptoms in some other organ. Cavernous sinus thrombosis 
makes itself evident by the swelling and edema of the upper part 
of the face and by exophthalmos, due to the backing up of blood 
from the cutting off of the intracranial return flow. The diagnosis 
may be very difficult, owing to the suppression of symptoms of 
phlebitis and thrombosis. 

Differential Diagnosis. — It is sometimes difficult to make a dif- 
ferential diagnosis .between cavernous sinus thrombosis, of otitic 
origin, and cavernous sinus thrombosis of nasopharyngeal origin. 
The points to be noted are, the condition of the ear and naso- 
pharynx. If the ear gives no local signs of infection which might 
be the cause of local thrombosis and the nasopharynx shows an 
infected condition, the diagnosis of thrombosis, of nasopharyngeal 
origin, is warranted. But, on the other hand, with a suppurating 
ear, the probabilities are very much in favor of an otitic origin tor 



558 DISEASES OF THE NOSE, THROAT AND EAR. 

the thrombosis independent of nasopharyngeal infection. Nasopha 
ryngeal thrombosis is of rare occurrence. 

Prophylaxis. — Prophylactic measures consist in the early treat- 
ment of the middle-ear infection and in a timely mastoid operation. 

Treatment. — Treatment is operative. The operation should not 
be delayed. 

Prognosis. — With early operation, the prognosis is good for 
recovery. A fatal issue may be expected if the cerebral vessels are 
extensively thrombosed, or if the thrombosis extends into the innomi- 
nate veins. 

Complications. — Complications to be feared are streptococcemia, 
extension of the thrombosis, brain softening, brain abscess, and 
metastases. 

LEPTOMENINGITIS AND INFECTIOUS HYDROCEPHA- 
LUS AND PYOCEPHALUS. 

Leptomeningitis, or inflammation of the meninges within the 
dura mater, and of the ventricles of the brain, is either serous or 
purulent. Serous meningitis is characterized by external or internal 
hydrocephalus, which may be localized, or may extend through the 
brain and spinal cord. Purulent leptomeningitis and internal 
pyocephalus may be confined to the vertex or the base; they may 
be diffuse or located in a subdural abscess or ventricle or they may 
extend through the brain and spinal cord. 

Etiology. — These inflammations are due to delayed mastoid 
operation and to the spread of infection from the middle ear to the 
pia, arachnoid and ventricles. 

Symptomatology. — The symptoms are a constant rise of tempera- 
ture ranging from ioo° to 103 for the serous meningitis and from 
103 to 107 for the purulent meningitis. Other symptoms of 
the disease are due to intracranial irritation and compression, 
associated with middle-ear disease. The symptoms of the two forms 
are similar except that in the purulent form the symptoms are more 
marked. These symptoms may be considered under two heads : 
first, the symptoms arising anterior to the tentorium and, second, 
those arising posterior to it. It must be borne in mind, however, 
that as the pathological condition becomes more grave, a lesion 
with its seat on either side of the tentorial wall will cause symptoms 



HYDROCEPHALUS AND PYOCEPHALUS. 559 

referable to the brain on the other side. Symptoms from in front 
of the tentorium are due to cerebral irritation and compression. 
These symptoms in cerebral irritation are severe headache and 
mental irritability. The symptoms indicating compression are 
choked disk; irregular, uneven pupils; pupils that react to distance 
and not light; contracted pupils, and coma. Posterior to the 
tentorium the symptoms from irritation are compression as shown 
in alteration of the neuro-muscular phenomena; rigidity of the 
muscles ; resistance to motion of the various joints, especially noticeable 
in movement of the neck and of the leg on the flexed thigh; inco- 
ordination of motion shown by inability to approximate the finger 
of the two hands with the eyes shut; increase or obliteration of 
tendon reflexes; vertigo, vomiting, and muscular incoordination and 
weakness. 

Localized meningitis may indicate its location by its influence 
on the function of local structures. When the meningitis is located 
about the left fissure of Rolando, motor paresis and paralysis 
is produced. Various paralyses of the extrinsic muscles of the 
eyes are found in meningitis of the base. Other cranial nerves 
also show effects of the meningitis. Optic neuritis is sometimes 
marked. 

Lumbar puncture will usually indicate increased cerebrospinal 
tension. In the purulent cases bacteria are usually found in the 
cerebrospinal fluid. 

Diagnosis. — The diagnosis is made upon the continued high 
temperature, intracranial irritation and indications of increased 
intracranial tension in connection with middle-ear infection. In 
internal pyocephalus pus is found in the cerebrospinal fluid. 

Prophylaxis.— Prophylactic measures consist in early mastoid 
operation and attention to the primary middle-ear infection. 

Treatment. — Treatment is operative for the relief of intracranial 
compression, cranial drainage of the infected area, and spinal 
drainage through lumbar puncture. 

Prognosis. — The prognosis is good for speedy recovery after 
drainage in the serous form; it is bad for purulent meningitis. 
Without operation purulent meningitis is always fatal. 

Complications. — The complications are cerebrospinal meningitis 
and brain abscess. 



560 DISEASES OF THE NOSE, THROAT AND EAR. 

INFECTIOUS ENCEPHALITIS OR INFLAMMATION OF 
THE BRAIN TISSUE— BRAIN ABSCESS. 

The pathology of infectious encephalitis includes non-suppurative 
or serous brain inflammations, tissue necrosis, brain softening, 
interstitial suppuration, and circumscribed brain abscess. The 
changes occur in several stages, viz., serous inflammation; necrosis of 
thrombotic origin, coagulation necrosis, followed by tissue soften- 
ing, and finally suppurative inflammation. The gross appearances 
are local hyperemia and serous exudation, gangrenous necrosis of 
the brain and meninges, cerebellar abscess and cerebral abscess. 

Etiology. — The infection extends from the middle ear usually 
by means of phlebitis; more rarely by direct interstitial extension. 

Symptomatology. — The symptoms are those of septic infection 
with low or medium temperature, 99 to 10 1°, associated with an 
infected ear as primary cause. The symptoms pointing to the 
intracranial seat of the lesions are, increased intracranial irritation 
and compression, choked disk, falling pulse rate with rising tempera- 
ture and severe headaches. Cerebral abscess may have focal symp- 
toms from the part of the cerebrum involved These symptoms 
are aphasia, motor impairment, paralysis, etc. Cerebellar abscesses 
sometimes have marked coordinational defect and alteration of 
the tendon reflexes. 

Diagnosis. — The symptoms of brain abscess are too indefinite 
to permit a positive diagnosis. The confirmation of the diagnosis 
should be tentative until operation. In the presence of focal 
symptoms the diagnosis is positive. 

Treatment. — Treatment is operative. 

Prognosis. — With early operation, the prognosis is for recovery 
in 50 per cent, of the cases. In delayed operation, the disease is 
usually fatal. 

Complications. — The complications are leptomeningitis, cerebro- 
spinal meningitis, and septicemia. 

SYSTEMIC COMPLICATIONS OF MAJOR SURGICAL 
DISEASE OF THE EAR. 

Mild inflammations and suppurative inflammations, usually 
in the larger joints and occasionally in the pleura, are the forms 
of metastatic inflammation of ear infections. 



MAJOR SURGICAL DISEASES OF THE EAR. 561 

Etiology. — The metastatic infection is due to metastatic spread 
and implantation of infection from otitis media, or its complications. 

Diagnosis. — The diagnosis is made on the local symptoms of 
infection in connection with the history of primary disturbances in 
the ear: 

Prophylaxis. — The prophylaxis consists in early mastoid opera- 
tion. 

Treatment. — The treatment consists, first, in the care of the middle 
ear and its complications; second, in general constitutional treat- 
ment, and third, in local and operative treatment of the metastases. 
The indication for operation is determined by the local conditions. 

Bacteriemias developing from ear diseases usually appear in 
the form of streptococcemia, and indicate sinus phlebitis and 
thrombosis. 

Etiology. — In these diseases streptococci have passed from the 
middle ear to the veins and have entered the general circulation. 

Symptomatology. — The symptoms are high, saw-toothed tempera- 
ture curve, with bacterial findings in the blood. 

Diagnosis. — The diagnosis is determined by the high, rapidly 
fluctuating, febrile temperature and by the bacterial findings. 

Prophylaxis. — The prophylaxis consists in early tympanic drainage 
and mastoid operation. 

Treatment. — The treatment is directed to local management 
of the ear and its complications; anti-streptococcic serum may be 
tried. Large quantities of water should be given by the mouth, 
saline laxatives, and rest in bed. 

Prognosis. — The prognosis is bad for recovery. 

Toxemia. — Toxemia from ear disease is due to the passage of 
toxins from the infected ear into the general circulation. The 
symptoms are a coated tongue, yellow skin, fetid breath, extreme 
weakness, high temperature, and weak, rapid pulse. 

Treatment. — The treatment consists in the eradication of the local 
cause, the free use of potable water by the mouth, of normal salt 
solution by the mouth and rectum, and of repeated small doses of 
magnesium sulphate, (about half-dram). 

AUTHOR'S BIBLIOGRAPHY. 

The Mastoid Operation: Indications for and Results from its Employment. 
N. Y. Med. Jour., June 29, 1907, vol. Ixxxv, No. 20. p. 12 12. 
36 



562 DISEASES OF THE NOSE, THROAT AND EAR. 

A Case of Thrombosis of the Posterior Cerebral Veins and Artery, Encephalitis, 
Purulent Leptomeningitis, Lateral Sinus Thrombosis Following Mastoi- 
ditis. Annals of Oto., Rhin. and Laryn., St. Louis, March, 1908, vol. 
xvii, Xo. 1, pp. 163-167. 

A Case of Streptococcus Encapsulatus Aural Infection, and Modified Radical 
Mastoid Operation. Archiv. of Otol., N. Y., Feb., 1908, vol. xxxvii, 
Xo. 1, pp, 69-72. 

Early Indication for Mastoid Operation. Int. Jour, of Surg., X. Y., Xov. 
1905, vol. xviii, Xo. 2, pp. 350-353. 

Exhibition of a Patient Operated on for Mastoiditis, Complicated by Epidural 
Abscess. Trans, of Amer. Otol. Soc, Xew Bedford, 1906, vol. x, Pt. 2, 

PP- 354-355- 
Epidural Abscess. The Post-Graduate, Xew York, June, 1905, vol. xx, Xo. 6, 

p. 591-592. 
Preventive and Abortive Treatment of Mastoiditis. X. Y. Med. Jour., 1909. 
Rapid Convalescence after Mastoid Operation. The Laryngoscope, St. Louis, 

April, 1907, vol. xvii, Xo. 4, p. 273-277. 
The Technic of the Complete Mastoid Operation, Improved, Shortened, 

and Simplified through the Digastric Route. Annals of Otol., Rhin. 

and Laryn., St. Louis, Dec. 1907, vol. xiv, Xo. 4, pp, 871-872. 
The Preventive and Abortive Treatment of Mastoiditis. The Antiseptic, 

Madras, India, Jan., 1907. 
The Technic of the Complete Mastoid Operation; Improved, Shortened, 

and Simplified through the Digastric Route. Trans. Am. Otol. Soc, 

Xew Bedford, May, 1907, vol. x, Pt. 3, pp. 461-463. 
Report of all the Mastoid Operations Performed by the Author at the Xew York 

Eye and Ear Infirmary, in 1907. Pub. in X. Y. Eye and Ear Infirmary 

Report, vol. xiii, July, 1908. 
Results of Improved Technic in Otologic Surgery. Jour. Am. Med. Ass'n, 

Chicago, Jan. 19, 1907, vol. xlviii, Xo. 3, pp. 200-205. 
The Radical Mastoid Operation, Modified to Allow the Preservation of Xormal 

Hearing. Trans. Am. Otol. Soc, Xew Bedford, 1906, vol. x, Pt. 2, 

pp. 292-295. 



CHAPTER XXXV. 

NASOPHARYNGEAL AND CONSTITUTIONAL TREATMENT OF EAR 

DISEASE. 

The vital importance of nasopharyngeal conditions as etiological 
factors in ear affections has been emphasized in the previous chapters. 
The grosser rhinopharyngeal conditions, such as occlusion of the 
nasal fossae, hypertrophies, osseous and cartilaginous deformities, 
new growths, and suppurative infections, have been thoroughly 
considered by Dr. Knight. 

There are, however, several minor disturbances of the naso- 
pharynx which, since they are often the cause of the most stubborn 
cases of ear diseases, deserve especial attention. Under this head 
we may group mild disturbances of the fossa of Rosenmuller, of 
Luschka's tonsil and the pharyngeal bursa, alteration of the circula- 
tion of the mucous membrane, and contact of mucous surfaces, 
especially contact between the outer surface of the lower turbinate 
and the nasal wall. These conditions affect the ear unfavorably 
by mechanical, inflammatory, toxic, and reflex disturbances. 

The lining of the fossa of Rosenmuller is subject to local hyper- 
trophy, infection, and adhesions with cicatricial contractions. 
These alterations, with the exception of the infections, interfere 
with the physiological movements — opening and shutting — of the 
pharyngeal mouth of the tympano-pharyngeal tube. We have 
already considered the effects of impaired tubal action on the ear. 

Luschka's tonsil and the pharyngeal bursa are often irritated or 
infected without showing much superficial change. Irritation of 
this region has, however, a marked reflex action upon the tympanic 
nerves, both through the nervous reflexes and through the local 
toxic effects on the sympathetic ganglia. 

The caliber of the Eustachian tube is subject to constriction by 
congestion of the mucous membrane, which extends into the tube 
from the nasopharynx and participates in the same changes as in 
the larger cavity. Contact of the mucous surfaces, especially of 
the outer surface of the lower turbinate and the nasal wall, has 

563 



564 DISEASES OF THE NOSE, THROAT AND EAR. 

marked influence on the ear by clogging the Eustachian tube. 
This obstruction of the tube is probably brought about by distur- 
bances in the circulation. The minor mechanical disturbances of 
the nasopharynx also interfere with the functions of the Eustachian 
tube. The minor inflammatory conditions interfere with the action 
of the tube by thickening the membrane, and predispose to otitis 
media by lowering the local resistance and by supplying the infecting 
organism. 

Reflex circulatory disturbances of the tympanum may originate 
from any pharyngeal irritation. The circulatory disturbances also 
follow the impairment of the sympathetic ganglion cells often 
accompanying minor infections of the neighboring membrane. 

The treatment for the minor nasopharyngeal conditions differs 
only in degree from that prescribed for the grosser conditions. 

Constitutional Treatment. — Next to nasopharyngeal influ- 
ences, the constitutional influences are the most important fac- 
tors in causing ear disease. These constitutional influences act 
in two ways: first, through disturbances of the mucous membrane 
in the nasopharynx, which in their turn affect the ear; and, second, 
through the blood stream, by disturbing the nutrition and conveying 
toxic material to the ear. 

All constitutional conditions which lower the vitality and are 
accompanied by toxic phenomena have a three-fold injurious 
effect upon the ear. First, by their alteration of the functions of the 
mucous membrane they disturb the action of the Eustachian tube. 
Second, by lowering the resistance they subject the middle ear to 
the infection which the altered mucous membrane cannot resist. 
Third, by their toxic effect upon the nervous supply of the ear. 
they cause trophic changes and thereby render the ear less able 
to resist the infection. The effect on the auditory nerve ganglion 
causes a hypersensibility and impaired function. The disturbance 
of the sympathetic system causes tympanic mucous membrane 
changes. 

Minor constitutional disturbances, digestive disturbances, anemia 
malnutrition, and nervous fatigue have an undoubted injurious 
effect upon the ear. Digestive disturbances frequently cause con- 
gestion of the mucous membrane of the tube and atrium, and con- 
sequently disturb the acoustic balance. Constitutional anemia and 
malnutrition may emphasize local anemia, with accompanying 



TREATMENT OF EAR DISEASE. 565 

impaired function of the middle ear and cochlea. The anemia 
often causes atrophic changes. 

The delicate adjustment of the neuro-muscular mechanism of 
audition requires the expenditure of considerable nervous force 
for the performance of delicate functioning. After general nervous 
exhaustion the supply of nerve force is so reduced that the demands 
of the auditory apparatus cannot be met, and consequently the 
function is impaired. 

The treatment of the constitutional conditions producing ear 
disease is naturally the usual treatment for ear diseases. Where 
the constitutional disturbances are of a minor nature, they require 
the general hygienic management which such disturbances demand, 
regardless of the ear complications. This treatment includes 
tonics, rest, and intestinal regulation. The toxic condition of the 
ganglion of the auditory nerve may be out of proportion to the 
constitutional symptoms of toxemia, which gives the ear symptoms 
marked prominence. This is sometimes the case with systemic 
bacterial intoxication but more often with drug toxemia — notably 
with quinine, salicylates, tobacco, alcohol, etc. The treatment is, 
first, removal of the cause. 

AUTHOR'S BIBLIOGRAPHY. 

Le Retrecissement de la Trompe d'Eustache dans les Maladies de Poreille et son 
Traitement. Archiv. Internat. de Lar. d'Otol. et de Rhin., Paris, May- 
June, 1905, vol. 19, No. 3, pp. 758-765. 

Stricture of the Eustachian Tube with its Baneful Consequences, Traced to 
Adhesions in the Fossa of Rosenmuller. Med. Record, New York, 
Feb. 8, 1908, vol. lxxiii, No. 6, pp. 217-218. 

Chronic Middle-ear Deafness. N. Y. Med. Jour., May 23, 1908, vol. lxxxvii, 
No. 2i, Whole No. 1538, pp. 990-992. 



CHAPTER XXXVI. 

SURGICAL TECHNIC. 

MAJOR AURAL SURGERY. 

Mastoid Surgery. — Mastoid surgery is directed to thorough 
drainage and complete evacuation of the infected tissues through 
their whole extent and ramifications, commencing at the mastoid 
and extending into the brain and neck. All operations for mastoidi- 
tis and its complications are begun with the same technic. The 
course and details of the operation cannot be foretold except in a 
small proportion of cases. Such procedures are followed as the 
disclosed inflammatory conditions demand. 

Previous to the operation, the bowels should be evacuated by 
a dose of 4 grains of calomel to the average patient, followed in two 
hours by a saline laxative, one-half ounce of magnesium sulphate, 
and in two hours by a soapsuds enema. A careful physical examina- 
tion of the heart and lungs and a urinary analysis are absolutely 
necessary before the administration of an anesthetic. In order to 
avoid the mental shock of walking into the operating-room, the 
patient should be put under primary anesthesia in his bed. After 
the commencement of the anesthesia, an area not less than two 
inches wide all around the ear should be shaved clean. With 
women, after the shaving, the hair is carefully drawn back from 
the scalp and a strip of gauze an inch wide applied along the hair 
margin with flexible collodion. This is a very useful measure 
during the postoperative dressings, as it keeps the hair from the 
wound. 

The general technic in ear surgery is similar to that used in other 
branches of surgery. Rigid asepsis and antisepsis is an absolute 
necessity if good results in aural surgery are to be obtained. It 
is desirable to have the operative field sterile as in abdominal 
operations, and as much effort should be bestowed upon the aural 
field, especially as its anatomical configuration makes it particularly 
hard to sterilize. The skin is sterilized by Harrington's solution, 

566 



MAJOR AURAL SURGERY. 



567 



which is washed off in three minutes with sterile water. The canal 
is then syringed with alcohol and packed with gauze. 

Sterile instruments and sterile dressings are a necessity. If 
the operator handles the wound, he should protect the patient by 
wearing rubber gloves. In doing mastoid work, he should also 
wear a cap, a veil, and a sterile gown with sleeves. 

The surgeon must take every possible precaution not to infect 
sterile tissues and cavities. If infection already exists, it must 




I 1 w 



Towel 



Towel I 




Mastoid ProWss ' ••..p;*' / : /ftrtoU of Jaw 



Fig. 214. — Shows adjustment of towels about operative field, lines of different incisions 
and landmarks; 2. first towel wrapped around head, covering hair; 3. second towel 
to protect the back part of head and neck; 4. third towel, covering face and field of 
anesthesia. The different cuts are AB, AC, AD, ABE, ABCE, ABCDF 



not be complicated by adding new species of pathogenic bacteria, 
since the complication of the infection greatly increases the virulencv 
of the disease. 

A sterile sheet is placed on the patient up to the neck. In order 
to protect the wound, sterile towels are placed in the following 
positions: One towel, towel No. 2 of the figure, is wound around 
the head to cover the hair. Towel No. 3 is fastened to towel 
No. 2 and to the sheet; this forms the posterior protection of the 



5 68 



DISEASES OF THE NOSE, THROAT AND EAR. 



operative field. Towel 4 is fastened to Towel 2 at the top of the 
sheet, thus forming the anterior protection of the operative field. 
This towel forms the barrier between the operative and anesthetic 
fields. 

Since in most cases it is impossible to foretell the extent of an 
aural infection before exploration, it is not wise to plan the exact 
extent and character of any operation to be performed. It is better 
to begin systematically to remove the diseased tissue and to explore 
the extent of the involvement, prepared to follow out any complica- 
tions that are disclosed. In every case, all the air cells should be 
opened to prevent postoperative extension and recurrence. The 
wound should be irrigated from time to time with isotonic salt 
solution in order to keep it damp and clear of blood. 

GROOVE TEMPORAL ARTERY 

\ POSTERIOR ROOT ZYGOMA 
SUPRA MASTOID RIDGE \ , MIDDLE ROOT ZYOOMA 

ANTERIOR ROOT ZYGOMA 



PARIETAL 5^ 

BONE 




GLENOID FOSSA 



GLASERIAN FISSURE. 
AUDITORY PROCESS 



TYMPANIC PLATE 
VAGINAL PROCESS 



MASTOID FORAMEN 

MASTOID PROCESS 



STYLOID PROCESS 



EXT. AUDITORY MEATUS 
TYMPANIC FISSURE 



Fig. 215. — Outer Surface of Right Temporal Bone. 



Before commencing the mastoid operation, it is wise to thoroughly 
incise the drum membrane. The mastoid incisions are extended 
as the conditions require, from A to B, B to C, B to E, C to D, and 
C to F. The primary incison, AB (Fig. 214), is made through the 
skin down to the periosteum. When the bleeding is controlled, the 
periosteum is cut and carefully lifted in unbroken sheets with the 
periosteum elevator, pushing the flaps forward and backward, and 
removing with them the attachment of the sternocleidomastoid mus- 



MAJOR AURAL SURGERY. 



569 



cle. The tip of the mastoid process is now exposed and the periosteum 
separated from the under and inner surface by passing the perios- 
teum elevator underneath the tip, well up into the digastric fossa. 
The bleeding is controlled, the retractors are adjusted and the tip. 
of the process is completely removed by the use of a larger rongeur 
(Fig. 216). 

If the appearance of the bone suggests an extension further than 
the simple involvement of the mastoid process, a cut, BC (Fig. 214.), is 




• / 



Su/ar\airYie<tt^l 
Spine 

.osterVor»U4il 
.Meatus 






Fig. 216. — Commencement of a Mastoid Operation. Adjustment of the retractor. 
Exposure of the cortex of the mastoid process, retraction of flaps and morcellment of 
the mastoid tip with the large rongeur. 



added. If there is posterior extension, the cut in the direction 
BE (Fig. 214) is also made, and the periosteum carefully lifted 
from the bone. As much of the diseased area as possible is removed 
with the large rongeur and with the smaller rongeur (Fig. 229, 
No. 1). In ordinary cellular bones, these instruments are sufficient 
to remove the external cortex and mastoid cells and to thoroughly 
open the antrum. 

Fig. 217 shows a bone like Fig. 215, after the tip of the mastoid 
process and the outer cortex have been removed, all the cells and 



57° 



DISEASES OF THE NOSE, THROAT AND EAR. 



the antrum have been opened with the rongeur. It must be em- 
phasized again that the infected areas must be sought, followed 
out and completely removed. In the particular specimen shown in 
Fig. 217, the cellular area has extended down from the mastoid 
region into the jugular process of the occipital bone as far as the 
condyle. The edges of the bone wound should be carefully levelled 
and two-thirds 1 of the posterior meatal wall removed, in order to 
leave as smooth a surface as possible for the reception of the skin flap. 

PARIETAL 



CONVEXITY OF THE 
SIGMOID GROOVE 



TEM PORO- PARI ETAL 
SUTURE 



5UPER10R 
PETROSAL CELLS 




TEM PORO- OCCIPITAL 
SUTURE 

OCCIPITAL 
MASTOID CELLS EXTENDING fftNtW i f 
INTO OCCIPITAL BONE tUNDYLfc 



MIDDLE 
EAR CAVITY 

STYLO- MASTOID / jp 
FORAMEN Xy^ 

MASTOID CELLS EXTENDING 
TO JUGULAR BULB 



Fig. 217. — Complete Mastoid Operation. 



Before [closing the wound, the bone surfaces should be smoothed 
with a Richard's curette (Fig. 229, No. 22) and the bony trabecular 
completely removed. Through the posterior wall of the mem- 
branous canal, a slit should be cut from the inner end of the bony 
canal to the external meatus (see Fig. 223). 

In the rare cases in mastoid operations, in which the sigmoid sinus 
has such an extreme anterior position that there is not room enough 



MAJOR AURAL SURGERY. 



571 



to enter the antrum between the groove of the sinus and the posterior 
wall of the auditory canal, the sigmoid sinus and the neighboring 
dura is denuded of bone and pressed out of the way to allow free 
access to the antrum. 

Fig. 218 shows the same bone when the involvement has extended 
forward to the epitympanum. This involvement requires what 
is called a " modified radical operation." The ossicles are left in 
position, the outer wall of the epitympanum is removed down to 



EMINENCE OF EXTERNAL 
SEMI- CIRCULAR CANAL 



HEAD OF HAMMER 



CRISTA TEGMEN1S 



SUSPENSORY 

LIGAMENT OF 

HAMMER 




Fig. 218. — Same bone. Author's modified radical mastoid operation. The outer 
wall of the epitympanum has been removed, leaving the ossicles in position. All J he 
work done on the bone shown in the figure was done with rongeurs. 



the attachments of the ossicles and the posterior wall of the osseous 
canal down to the attachment of the drum membrane and the 
safety line of the facial nerve. This nerve lies internal to a line 
connecting the stylomastoid foramen and the sulla incudis, the 
posterior attachment of the incus. 

Fig. 219 shows the same bone where it was necessary to perform 
what is called a "radical operation," because of the presence of 
extensive bone involvement in the tympanum as well as in the 



572 



DISEASES OF THE NOSE, THROAT AND EAR. 



mastoid. In this case part of the upper anterior tympanic wall, 
all of the upper external wall, and as much of the posterior meatal 
wall as the position of the facial nerve would allow have been 
removed. The same specimen shows some small zygomatic cells 
opened. 

Previous to the operation this case showed constitutional symptoms 
of thrombosis of the sinuses. When the bone was opened a diseased 
tract was found to lead to the dura mater of the descending limb 
of the sigmoid sinus, and consequently this part of the sinus had to 



ASCENDING ARM OF 
SIGMOID SINUS 
UNCOVERED 



EMINENCE OF EXTERNA*. 
SEMt-CtRCULAR CANAL 

2YG0MATIC CELLS 
FACIAL RIDGE 
OVAL WINDOW 



PROCESSUS 
COCHLEARIS 



PROMONTORY 



ROUND WINDOW 




Fig. 219. — Same bone. After the performance of the radical mastoid operation 
Shows the exposure of the descending limb of the sigmoid sinus. 



be uncovered, revealing a pachymeningitis and an epidural abscess, 
which in this locality is an episinus abscess. The dura mater was 
further uncovered until a margin of healthy dura mater was exposed 
all around the diseased area. 

The sinus felt hard and it was therefore decided to explore for 
sinus thrombosis. The sinus at both ends of the exposed area was 
compressed by pledgets of iodoform gauze, and the sinus incised 
longitudinally between them. A clot was found and removed. 
Loosening the gauze pledgets one at a time and quickly replacing 



MAJOR AURAL SURGERY. 573 

them allowed free bleeding in both directions. All the bone work 
shown in the figure was done with the rongeurs. A plastic flap 
(Fig. 223, A) was cut in the soft meatus. The ends of the compresses 
on the cut ends of the sinus were led out of the meatus. The 
mastoid incision was closed with a subcutaneous silkworm-gut 
suture. The wound was lightly packed through the meatus, care 




Fig. 220. — A diagram of a mastoid operation when the bone involvement required 
exposure of the signoid sinus or the middle fossa of the skull. (Oppenheimer.) 

being taken, to press the meatal flap up and back firmly. The usual 
dressings were applied. 

Fig. 221 shows the same bone. Because of the diseased condition 
of the dura mater, a further extension of the exploration of the sinus. 
with exposure of part of the lateral sinus and horizontal limb of 
the sigmoid sinus and jugular bulb was demanded. Thrombosis 
was evident from the discoloration and hardness of the sinus wall. 
The exposure was extended backward until the healthy dura was 



574 



DISEASES OF THE NOSE, THROAT AND EAR. 



uncovered. Forward the exposure was continued to the jugular 
bulb. The uncovered sinus was blocked off at both ends with 
gauze pledgets and opened longitudinally with a knife. The 
clots were evacuated and when the gauze compress was loosened, 
bleeding was obtained from the posterior end of the incision. Since 
in this case no bleeding was obtained from the lower end, it was 
evident that the clot extended into the jugular bulb. It was thought 
wise, therefore, to expose, ligate, and remove the internal jugular vein. 
The diseased bone also led into the external semicircular canal and 



ANTERIOR SEMI-CIRCULAR CANAL 




EXTERNAL SEMI- CIRCULAR 
CANAL AND VESTIBULE 



VESTIBULE THROUGH 
ENLARGED OVAL 
WINDOW 

OPENING IN 
TYMPANIC LIMB 
OF FACIAL CANAL 
71,1,1,, ,. INNER WALL 
OF COCHLEA 
PROMONTORY 
REMOVED 
EUSTACHIAN TUBE 



STYLO -MASTOID 
^ v FORAMEN 



DESCENDING ARM 
OF SIGMOID SINUS 



HORIZONTAL 
OF SIGMOID 



OCCIPITAL CONDYLE 



JUGULAR PROCESS OF, 
OCCIPITAL BONE FILLED^ 
WITH MASTOID CELLS 



Fig. 221. — Same bone as Fig. 215. Radical mastoid operation has been performed, 
together with evacuation of the labyrinth, and exposure of the lateral and sigmoid 
sinuses and the jugular bulb. 



internal ear. Consequently, the diagnosis of labyrinthine suppura- 
tion had to be made while the patient was on the table. The 
semicircular canals were opened by removing with scissor forceps 
the labyrinthine capsule that lay over the canals in the solid angle. 
The outer wall of the cochlea was also removed with the dental 
scrapers and scissor forceps (Fig. 229, No. 2). The vestibule 
was opened above the facial canal through the anterior part of the 
external semicircular canals. The oval window was enlarged 
below the facial canal. The lower whorl of the cochlea was opened, 
and the outer wall of the pyramid of the cochlea entirely scraped 



MAJOR AURAL SURGERY. 



575 



away. The facial canal was accidentally opened at two points, 
but the nerve was in no way injured. 

Fig. 222 shows the same bone in a case having symptoms of cerebral 
and cerebellar abscess. During the operation, the surgeon was 
compelled, in order to remove all the diseased bone, to uncover 
the dura mater of the cerebellar and middle cerebral fossae. The 
dura mater showed evidence of pachymeningitis by its thickening 
and deep red color. A small sinus was found leading through the 
dura mater into the cerebellum and another into the temporo- 



DURA MATER 

OF "-JSTERIOR FOSSA 



POSTERIOR-SUPERIOR 
ANGLE PETROUS BONE 




DURA MATER 
OF MIDDLE FOSSA 



EMINENCE OF EXTERNAL 
SEMI-CIRCOUAR CANAL 



FACIAL RIDGE 
PROCESSUS 

COCHLEARS 
OVALWINDOW 
PROMONTORY 



ROUND WINDOW 



Fig. 222. — Same bone. Radical mastoid operation has been performed. Exposure 
of field of cerebral abscess and exposure of field of cerebellar abscess. 



sphenoidal lobe. The bone about the sinuses was removed until 
healthy dura mater was uncovered in all directions. The dura mater 
was incised in both localities by an X-incision, which exposed the 
whole of the infected tracts in the temporo-sphenoidal lobe and 
cerebellum, and a large quantity of thick, green foul pus was 
excavated. The incisions were so broad that it was not necessary 
to insert drains in the brain wounds. 

The completion of an operation in the temporal bone surgery 
requires that the osseous field of operation should be left with 
a smooth and even surface, bare of congested or necrotic bono. 



576 



DISEASES OF THE NOSE, THROAT AND EAR. 



The edges of the bone wound should be rounded off as smooth as 
possible to allow coaptation of the soft parts. 

The membranous and cartilaginous meatus is slit according to 
the kind of operation that has been performed (see Fig. 223). When 
only part of the posterior osseous wall of the meatus has been 
removed, the cut B is made from the drum membrane along the 
posterior wall of the canal to the posterior lip of the external orifice. 
When the whole of the posterior osseous wall of the meatus has been 
removed, the cut A is made, forming a plastic flap to be pressed 




Fig. 223. — The right meatus stretched open; the curved line A indicates the line of inci- 
sion for the plastic flap in the radical mastoid operation. The line runs along the floor 
of the canal to the concha, then turns backward and upward. The straight line B 
indicates the line of incision along the posterior wall of the canal, in the author's 
modified radical operation and in the author's complete mastoid operation. 



up and back by the dressing. This cut is made along the entire 
length of the membranous and cartilaginous meatus, and upward 
through the anterior third of the concavity of the concha to a leve) 
opposite the upper wall of the meatus. 

Closure of Wound. — Before closing, the wound should be thoroughly 
washed with isotonic salt solution. The question of drainage of 
the wound is determined by the condition in which the wound is 
left. If the wound is clean and smooth and without any inflamed tis- 
sues or tissues which have been contused by the operation, drainage 



MAJOR AURAL SURGERY. 577 

can with safety be reduced to a minimum. In these cases, the surgeon 
uses a small cigarette drain, half the diameter of a lead-pencil and 
made by a layer of rubber tissue and a layer of gauze rolled tightly. 
The drain is placed at the lower angle of the incision, extending to 
the deepest portion of the wound. If there are infected or contused 
tissues left in the wound, larger drainage in proportion to the area 
of these tissues is inserted. If extensive drainage is required the 
wound is packed with iodoform gauze, leaving sufficient room to 
remove the packing. The angles of the wound are sutured. When 
a radical operation has been performed, the drainage is provided 
through the enlarged meatus with gauze strips. 

When practicable, a few deep, periosteal sutures are used, one 
midway in each limb of the wound. Chromicized catgut sutures 
are best. The skin is sutured by subcutaneous silkworm-gut 
sutures, metal clamp sutures, or interrupted sutures. 

If a wound is to be closed around a small cigarette drain, it is 
desirable that when the wound is closed there should be blood 
enough to fill all the air spaces. If the wound is not oozing enough 
for this, blood can be made to flow by gently scraping the skin 
margin with a curette. After the wound is closed the meatus is 
gently packed with iodoform gauze strips. 

Sufficient packing is used to slightly distend the flaps cut in the 
membranous and cartilaginous canal. After the radical operation 
the plastic meatal flap is pressed firmly backward by firm packing. 
Care should be exercised not to allow the packing to touch the drum 
membrane or the middle-ear contents, unless the radical operation 
has been done. A small doughnut of absorbent sterile gauze, 
wrung out in saline solution, is placed around the ear, and a small 
gauze handkerchief, also moistened, is placed over the ear. The 
whole is well covered with a piece of sterile rubber tissue. Over 
this is laid a large piece of sterile absorbent cotton and last a roller 
bandage, applied from below up and from the eye of the affected 
side toward the affected ear. This bandage presses the ear upward 
and backward into its normal position, supports the ear in this 
position, and holds the dressings in place. 

Postoperative Treatment. — The special object of the treatment 

after operation is to continue drainage and to prevent infection. 

In order to minimize deformity or functional incapacity and to 

hasten repair, the plastic management of the wound requires constant 

37 






578 



DISEASES OF THE NOSE, THROAT AND EAR. 



attention to asepsis and to all details. The dressings are changed 
the day following the operation. The packing in the meatus and 
the drain in the wound are not removed unless there are signs of 
infection of the canal. On the second day all the dressings, both 
packing and drain, are removed. The canal is filled with boric 
acid powder and the wet dressing again applied. On the third and 







-, 





Fig. 224. 



-Shows mastoid bandage applied. It passes wholly above the 
sound ear. (Whiting.) 



subsequent days, the wound is dressed in the same way until the 
discharge ceases and the redness of the wound has disappeared. 
When these have ceased, boric acid is dusted upon the wound and a 
dry dressing applied until healing is complete. At each subsequent 
dressing, the meatus is wiped out with sterile cotton applications 
and sterile boric acid powder insufflated. The skin sutures are 
removed between the second and fourth days. Inflation of the 



MAJOR AURAL SURGERY. 



579 



middle ear is practised from the first, either by Valsalva's method or 
by Politzeration. Catheterization should not be used until the 
patient is well along in convalscence. 

The Technic of the Management of Infected Operative Wounds. — 
Various methods of cleansing infected wounds are to be tried until 
the one most satisfactory in the individual case has been determined. 
It is best to begin in the sthenic cases with the aluminum wash 




Fig. 225. — Lumbar Puncture. Diagram showing the lumbar intervertebral spaces, 
and the position of the canula in lumbar puncture. The line connecting the crests of 
the ilia passes above the last lumbar spine. The largest intervertebral space is the 
one below this spine. 



No. 12 and in the asthenic cases with the red zinc sulphate wash 
No. 10. Other dressings to be used are painting with tincture of 
iodine, alcohol 50 per cent., creoline poultice 1 to 1000, corrosive 
sublimate poultice 1 to 5000, and carbolic acid poultice, 1 to 40. If 
a wound, which has been packed, does not granulate sufficiently 
rapidly, it can be stimulated with the red wash poultice and with 
balsam of Peru application, or with tincture of iodine. 



5 8o 



DISEASES OF THE NOSE, THROAT AND EAR. 



Lumbar Puncture. — The lower lumbar region is carefully sterilized 
with Harrington's solution (No. 8). A strong hollow needle three 
inches long is selected and carefully sterilized. The patient is made 
to bend the back forward in order to open the inter- vertebral spaces. 
A convenient method is to have the patient sit on the edge of the bed, 
and rest his elbows on his knees. Fig. no shows that the inter- 
vertebral space between the sacrum and the last lumbar vertebra 
is the widest. This space is the second intervertebral space that 
lies below a line drawn across the tops of the crests of the ilia. The 




Fig. 226. — Second Stage of the Auditory Nerve Resection Operation. The figure 
shows the tentorium and upper surface of the petrous pyramid exposed, and incision 
in the tentorium parallel to the posterior superior edge of the petrous pyramid. 



spinous process of the last lumbar vertebra lies below the cross 
line and just below this lies the largest intervertebral space. The 
needle is plunged in at right angles to the surface, about one-eighth 
of an inch from the median line. The distance the needle has to 
go inward in order to pierce the dura mater varies with the age, 
size, and muscular development of the patient. The flow of fluid 
is spontaneous when the dura mater is pierced. The needle, 
if properly directed, will not meet a solid obstruction until it touches 
trie anterior wall of the spinal canal. If the field of the needle 
indicates that it has entered and traversed the spinal canal and 



MAJOR AURAL SURGERY. 



581 



reached the anterior wall without the appearance of any fluid, the 
needle is probably occluded. It should be withdrawn cleaned and 
reinserted. If there is only a gentle trickle of fluid, 20 c.c. may be 
withdrawn; if there is evidence of extreme tension the fluid spurts 
out briskly. In this case enough fluid should be withdrawn to 
reduce the tension to normal, When the amount of fluid desired 
has been drawn off the needle is withdrawn and a small sterile dress- 
ing applied. 
Surgery of the Auditory Nerve. — A method of resection of the 




Fig. 227. — Third Stage of the Resection of the Auditory Nerve. The auditory 
nerve is seen at the bottom of the incision in the tentorium. 



auditory nerve for grave tinnitus is through an operative field 
extending from behind the auditory meatus on a level with the 
tentorium inward along the posterior edge of the petrous pyramid 
through the tentorium near its attachment directly to the orifice 
of the internal auditory meatus, where the auditory none is revealed 
as a bright white cord nearer the surgeon than the facial nerve. 
The auditory nerve should be grasped with forceps and avulsed or 
it can be severed with sharp hook or scissors. This opera 1 ion is to 
be used as a last resort, when the patient has an unendurable tinnitus. 
Surgical removal of the Gasserian ganglion, its branches and 



582 DISEASES OF THE NOSE, THROAT AND EAR. 

roots, can be done through the otological opening which is used to 
expose a temporal lobe abscess — the dura mater is elevated, the 
brain tissue compressed, the apex of the anterior surface of the 
petrous bone exposed, and the ganglion and its branches removed. 

Facial Paralysis. — In recent cases of traumatic facial paralysis 
the injured ends of the nerve can be dissected out and sutured. 
The prognosis is good for a satisfactory result if sufficient slack 
be found to allow the ends to be united. In traumatic facial pa- 
ralysis of long standing direct repair of the nerve is usually impossible. 
In these cases if the facial nerve can be found it can be anastomosed 
with the hypoglossal with the expectation of a partially satisfactory 
result. 

Operation for Decompression of the Brain. — The otological 
operations for intracranial tension are performed by extending the 
field of a mastoid operation so that the cerebral or cerebellar dura 
mater will be exposed (see Fig. 69). Incision of the exposed dura 
will drain the arachnoid space. Puncture of the lateral ventricle 
will drain the ventricular system. 

MINOR AURAL SURGERY. 

Minor aural surgery is directed to the drainage and excision of 
infected areas, to drainage of othematoma and removal of benign 
tumors, to the correction of deformities, cicatricial contractions and 
adhesions, repair of wounds, and to local depletion. The external 
skin and meatus are sterilized in the same way as for major opera- 
tions. 

Before attempting cosmetic surgery of the auricular deformities, 
a cast of the ear should be taken,, the size of the piece of cartilage 
to be removed noted on the cast, the site selected and measured and 
the operation carefully planned. At the time of operation the cast 
should be used to direct the minutiae of the operation. 

Deformities of the pinna, due to superabundant cartilage, are 
corrected by lifting the skin on the posterior side of the cartilage 
to be removed and taking out the cartilage, together with its peri- 
chondrium. The incision should be made in the hollow of a fold 
of the auricle, and should always be on the posterior side. If the 
cartilage to be removed lies along the border of the concha, the 
operation consists merely in the removal of enough of the edge of 



MINOR AURAL SURGERY. 583 

the cartilage to reduce the pinna to the desired size. When the 
bleeding has ceased, the skin is carefully sutured with fine horse- 
hair sutures and a collodion dressing applied. The dressing consists 
of a strip of gauze folded over on both sides of the operative field, and 
coated with flexible collodion. This operation is selected when 
the upper and posterior borders of the pinna are too large. 

If the superabundant cartilage lies toward the center, as well as 
at the periphery of the pinna, a wedge-shaped piece with the base 
at the periphery is removed. Enough cartilage should be removed 
to make the auricle of proper size and shape. All bleeding is 
stopped and the cut edges of the cartilage are carefully adjusted 
and held in place by perichondrial sutures of fine catgut. The 
skin flaps are treated as in the previous operation. This operation 
is for cases where the whole concha is too large. 

When the concha is too small at the periphery of the pinna, 
causing the ear to be cup-shaped, a lenticular strip of cartilage can 
be removed from the concha enough to contract the concha and to 
restore the ear to a normal appearance. The wound and suture 
are arranged as in the previous operation. 

When the deformity of the auricle is caused by undue prominence, 
or to misshapen folds of the pinna or concha, the defects are corrected 
by uncovering the perichondrium over the seat of the concavity of 
the desired fold, and by passing fine silk sutures through the peri- 
chondrium at two points which are placed on the edges of the desired 
fold and drawing them together to form the fold. Several sutures 
should be used in order to divide the strain and to prevent pulling 
out. After this cosmetic operation, a retention dressing must be 
put on with a roller bandage, and later a bandage or cap must be 
continually worn for two or three months. 

When the pinna stands out at right angles, the skin of the posterior 
auricular fold is incised longitudinally, the skin loosened in both 
directions, and the perichondrium of the concha firmly sutured 
with silk to the mastoid periosteum in order to decrease the post- 
aural angle sufficiently to place the auricle in the desired position. 
In suturing the periosteum, as many sutures as possible should be 
used in order to equalize the strain. A retention dressing, as in the 
preceding operation, is required. 

Othematomata are treated by subcutaneous aspiration with a 
fine needle and firm compression between tin disks, padded with 



5^4 



DISEASES OF THE NOSE, THROAT AND EAR. 



cotton. The disks are held in position by elastic bands wound around 
the wires prepared for the purpose. 

Subperichondrial abscess is treated by multiple free incision and 
by wet dressing of acetate of aluminum wash No. 12, page 592. 

Excision of Branchial Cysts and Fistulce. (Fig. 1). — Owing to the 
small size of these capillary fistulous tubes it is necessary to inject 
them with some colored fluid before operating on them, as otherwise 
it is impossible to follow their course. A good injection medium 
is cocoa-butter and Prussian blue, warmed and injected with a 
middle-ear syringe and canula (Fig. 229,. No. 18). The dis- 
section must be made with care in order to avoid injuring branches 





Fig. 228. — A shows the compression splint for othematomata in place on the auricle. 
The splint is held in place and compressed by rubber bands. B shows inner side of 
one of the tin splints. C shows outer surface of one of the tin splints with strengthen- 
ing wire which is soldered on. 



of the facial nerve. The entire fistulous tract should be dissected 
out. This may require deep dissection in the neighborhood of 
the ear and the articulation of the jaw. The wound is closed around 
a cigarette drain and managed in the same way as a mastoid wound. 
Foreign bodies impacted in the meatus sometimes require operative 
assistance for their removal. The skin in the postauricular fold 
is cut, the posterior attachment of the cartilaginous canal to the 
bony canal loosened, and the auricle displaced forward, thus 
exposing the osseous canal from behind. The foreign body can 
then be removed. The auricle is replaced and carefully sutured 
to the periosteum of the mastoid with chromicized catgut. The 
skin wound should be closed by subcutaneous sutures of silkworm 



MINOR AURAL SURGERY. 585 

gut. The meatus is lightly packed with formalin gauze, and a 
gauze handkerchief followed by roller bandage completes the dressing. 
Care must be exercised that the ear does not droop. To prevent 
this, a cap should be worn for from six to eight weeks. 

Removal of Exostoses of the Canal. — The pedunculated exostoses 
may be broken loose with a blow from a blunt instrument, such as 
the handle of a dental scraper. The growth — unless it is extremely 
large and impacted — is readily removed by the method used in 
the removal of a foreign body. If the growth is impacted in the 
canal, the canal must be opened behind the auricle and the exostosis 
removed like an impacted foreign body. The sessile, deep-seated 
exostoses may require enlargement of the canal before they can be 
curetted away. The same technic is used as in the radical mastoid 
operation, except that only the anterior periosteal flap is lifted, and 
the mastoid cells are not opened. Only a part of the posterior wall 
of the canal is removed — enough to allow access to the bony growth 
and to facilitate its removal. The periosteum of the canal is raised 
as carefully as possible; after the exostosis has been scraped away 
with a sharp curette the membranous canal wall is slit longitudinally. 
The posterior aural wound is closed with a peritoneal suture of 
chromicized catgut, and the skin flaps are united by subcutaneous 
sutures of silkworm gut. The meatus is lightly' packed with formalin 
gauze. 

Stricture of the External Auditory Canal. — Annular strictures 
are treated by multiple incisions and packing. The packing should 
remain in for forty-eight hours. When there is extensive atresia 
of the canal, the same technic is followed as described for deep 
exostosis of the canal. It is an adaptation of the technic for the 
radical mastoid operation. 

Furuncles and abscess of the canal are treated by wide and deep 
incision through the infected area to the cartilage. If the abscess 
has extended and passed beyond the limits of the cartilaginous 
meatus, a wide incision through the cartilage down to the periosteum 
is required, and sometimes a counteropening through the skin 
adjacent to the auricle, over the point of swelling. When an anterior 
incision is made, care must be taken not to injure the capsule of 
the mandibular articulation or branches of the facial nerve. The 
wound is wiped with pure carbolic acid, then with alcohol, and 
both the wound and the meatus are packed with iodoform gauze. 



586 DISEASES OP THE NOSE, THROAT AND EAR. 

If an external wound has been made it is closed and drainage is 
made through the canal. 

Post-aural fistula; leading into the mastoid antrum, sometimes 
occur after spontaneous or operative drainage of the mastoid antrum. 
If they are not healed, they require a complete mastoid operation; 
if healed, a plastic operation is required to allow the skin flaps to be 
united properly. For this purpose it is best to resect the skin freely 
and to remove all the bone that hinders the approximation of the 
skin flaps and the obliteration of the sinus cavity. A free opening 
into the membranous meatus should be made for drainage, and the 
posterior wound closed with subcutaneous sutures. 

OPERATION OX THE TYMPANIC MEMBRANE: 
MYRINGOTOMY. 

Following the cuts shown in the diagram. Fig. 211, No. 1. the 
membrane is incised with the myringotome Fig. 229. No. 9). The 
patient's head must be kept steady to allow deliberate incision. 
Local or general anesthesia is usually required. For local anesthesia 
use solution No. 3. The most convenient general anesthetic to give 
is ethyl chloride. 

Ossiculectomy. — In order to allow drainage in chronic middle-ear 
suppuration, it is occasionally thought wise to remove the major 
ossicles. Local anesthesia is necessary for ossiculectomy. After 
the ear has been syringed out with alcohol followed by sterile water, 
a 20 per cent, solution of cocaine in 1-1000 adrenalin, is instilled 
into the middle ear. The ear is plugged with cotton. The cocaine 
is left in from ten to twenty minutes. If the cocaine passes into 
the pharynx, care must be exercised that poisoning does not result. 
When anesthesia is complete, the meatus and middle ear are wiped 
dry. and the remnants of the drum membrane are incised close 
to and parallel to the handle of the hammer. The small ring knife 
■Fig. 229, No. 5) is passed over the handle of the hammer, and 
pressed upward cutting the ligaments and tendon of the hammer, 
and the hammer drawn out in the ring. With a small-angle knife 
(Fig. 229. No. 8) the incus is separated from the stapes. Then with 
the incus hook 'Fig. 229. No. 10; placed carefully over and behind 
the incus, forward rotation will bring the incus out into view and 
it can be removed with the alligator forceps Tig. 229, No. 3). 



OPERATION ON THE TYMPANIC MEMBRANE. 587 

Subsequent treatment is the same as for suppurating cases. No 
packing is necessary. 

Removal of polypi and granulations can be done under direct 
observation with the alligator forceps (Fig. 229, No. 3). Local 
anesthesia is usually necessary. Care must be taken not to dislo- 
cate the ossicles or remove tympanic structures. 

Exploratory tympanectomy is employed for intratympanic examina- 
tion for adhesions. With the myringotome (Fig. 229, No. 9), 
a triangular flap is cut in the posterior-superior quadrant of the 
membrane, its base being downward. This exposes the stapes 
and the tip of the long process of the incus and promontory. Inspec- 
tion with a magnifying lens will reveal any adhesions in the neighbor- 
hood. When the inspection is complete the flap is gently pressed 
back into position, and the canal closed with a little absorbent cotton. 
The ear should be inspected every day until the union of the flap 
has obliterated the perforation. 

The operative treatment of tension anomalies requires intra- 
tympanic severing of the adhesions of the drum membrane and 
ossicles with the angle knife (Fig. 229, No. 8). The same incision 
is used as has just been described. 

For local depletion, wet cupping is sometimes used. It is to be 
applied over the mastoid antrum or over the mastoid foramen 
for mastoid and tympanic inflammations. For inflammations of 
the canal, cupping in front of the tragus will give relief. The skin 
is incised with a sharp knife or artificial leech, and suction applied 
with a hot bottle with suction bulb or air pump. 

AUTHOR'S BIBLIOGRAPHY. 

Operative Technic and After-treatment for Mastoiditis with Epidural Compli- 
cations. Med. Record, N. Y., March 31, 1906, vol. lxix, No. 31, pp. 
502-5. 

Technic of the Radical Tympanomastoid Operation when complicated by the 
Anterior Position of the Sigmoid Sinus. N. Y. Med. Jour., April 14, 
1906, vol. lxxxiii, No. 15, pp. 751-54. 

Mastoideotympanotomy: The Operation of Election for Persistent Otorrhea 
and Acute Mastoideo-tympanic Ostitis. Post-Graduate Quadri-Cen- 
tennial, 1908, New York. 

Short and Easy Methods of Arriving at Good Results in Disease of the Ear and 
Upper Air Tracts. Illustrated by Recent Cases. Med. News. X. Y., 
vol. lxxxvi, 1905, p. 393. 






588 DISEASES OF THE NOSE, THROAT AND EAR. 

The Conservation of Hearing in Operations on the Mastoid Region. Boston 

Med. and Surg. Jour., March, 1907, vol. clvi, No. 10, p. 300. 
Results of Improved Technic in Otological Surgery. Jour, of the Amer. Med. 

Asso., Chicago, vol. xlviii, 1907, pp. 200-205. 
Le Caillot Modifie dans la Chirurgie de la Mastoide. Archiv. Internat. de 

Laryn. d'Otol. et de Rhin., Paris, Sept., Oct., 1906, vol. xxii, No. 2, pp. 

501-504. 
The Radical Mastoid Operation Modified to Allow the Preservation of Normal 

Hearing. N. Y. Med. Jour., vol. lxxxiv, 1906, p. 780. 
Report of a case with hysterical symptoms upon whom the mastoideotympanic 

operation was done. Both sphenoidal sinuses were opened and partial 

turbinectomy performed upon three turbinates, besides much local 

treatment. Am. Jour, of Surgery, N. Y., Sept. 1906, vol. xx, No. 9, pp. 

279-280. 
Some Modifications in the Operative and After-treatment of Mastoiditis. N. Y. 

Eye and Ear Infirmary Report, N. Y., 1906, vol. xii, pp. 81-91. 
Modified Blood Clot in Mastoid Surgery. Annals of Otol., Rhin. and Laryn., 

St. Louis, 1906, vol. xv, No. 3, pp. 489-492. 
The Technic of the Complete Mastoid Operation, Improved, Shortened, and 

Simplified through the Digastric Route. Annals of Otol., Rhin. and 

Laryn., St. Louis, Dec, 1907, vol. xvi, No. 4, p. 871-872. 
The Conservation of Hearing in Operations on the Mastoid Region. Annals 

of Otol., Rhin. and Laryn., St. Louis, 1907, vol. xvi, No. 1, p. 32-36. 
Two Cases of Otitis Media Catarrhalis Chronica, Showing Improved Hearing 

after Acute Mastoiditis Treated by Operation. Internationales Zentral- 

blatt f. Ohrenheilk., vol. vi, No. 2, Nov., 1908, p. 74. 
Rapid Convalescence after Mastoid Operations. The Laryngoscope, St. 

Louis, April, 1907, vol. xvii, No. 4, pp. 273-277. 
Capital Operation for the Cure of Tinnitus Aurium. Jour, of Am. Med. 

Assn., Chicago, vol. xiv, 1905, pp. 1787-1792. 
A Case of Mastoiditis and Epidural Abscess. Operation and Rapid Recovery. 

Trans. Am. Otol. Soc, New Bedford, May, 1907, vol. x, pt. iii, p. 503-9. 
A New Motor for Bone Surgery. Medical Record, New York, April, 1908, 

vol. lxxiii, No. 16, p. 872. Abstract in Internat. Zentralblatt f. Ohren- 
heilkunde, 1907, vol. v, No. 7, p. 322. 



CHAPTER XXXVII. 

THERAPEUTICS OF THE EAR. 

GENERAL THERAPEUTICS. 

General therapeutics of the ear include the remedies which have 
a special selective action on the ear, and those which, through their 
influence on the general system, have a favorable effect upon the 
ear. For alleviating inflammatory conditions in the ear, we use, 
besides rest in bed and light diet, magnesium sulphate as a laxative, 
potable water, saline high enemata, antitoxins, vaccines, epider- 
molysis, venous infusion of isotonic salt solution, and transfusion. 
In asthenic cases of functional disturbances, when the circulation, 
nervous and muscular systems are at fault, we use general tonic 
treatment, with especial attention to the circulation, digestion, and 
bowels. Strychnia in moderate doses is a powerful auditory stimu- 
lant. In the sthenic cases, with local congestion, we use depleting 
treatment with emetics, diaphoretics, such as pilocarpin, tartar 
emetic, and various purgatives. Quinine in doses from 2 to 3 
grains daily is often useful in cases of labyrinthine congestion with 
vertiginous symptoms. Syphilitic and tuberculous infections demand 
the well-known methods of treating the general system under these 
conditions. 

SPECIAL LOCAL THERAPEUTICS. 

SOLUTIONS. 

i. Mild Antiseptic. 

Saturated Solution of Boric Acid in Water. — A mild antiseptic 
solution which should be sterilized by boiling. This solution is 
used for syringing in subacute and chronic purulent cases when the 
discharge is abundant. It also serves as a vehicle for the thera- 
peutic use of heat in acute tympanic inflammations. For this 
purpose the solution is used as a douche in a fountain syringe 

589 



590 DISEASES OF THE NOSE, THROAT AND EAR. 

placed at very slight elevation, or it is dropped directly into the 
ear from a medicine dropper. The solution should be used as hot 
as can be borne, up to ioo°-iio°F. 

2. Hygroscopic Antiseptics. 

a. Saturated Solution of Boric Acid in Absolute Alcohol. — The best 
antiseptic astringent solution for use in the middle ear in subacute 
and chronic suppuration. A few cases will not tolerate it, and in 
a slightly larger number of cases it is inefficient. The solution 
is applied to the ear with a dropper after the ear has been wiped 
dry. It is ineffective when used after syringing. 

b. Saturated Solution of Iodoform in A b solute Alcohol. — A stimulating 
antiseptic solution, useful in some of the cases where solution a is 
ineffective. It is helpful in syphilitic ulcerative conditions. 

c. Commercial Alcohol. — Its chief use is as a destroying agent of 
the spores and mycelium of the aspergilli. It is used as a syringe 
solution or can be dropped into the canal with a medicine dropper. 

d. Absolute Alcohol. — An antiseptic hygroscopic solution for the 
middle ear. Leaves no residue. 

3. Astringent Antiseptics. 

a. One-half of 1 per cent, to 1 per cent. Solution of Nitrate of Sil- 
ver. — Strong astringent antiseptic stimulating solutions for appli- 
cation in the tympanic cavity or for use in the middle-ear syringe. 

b. Two per cent. Solution of Nitrate of Silver. — A more stimulating 
solution than a. 

c. Ten per cent. Solution of Argyrol. — Anon-irritating silver anti- 
septic solution for use in the tympanum. 

d. Twenty-five per cent. Solution of Argyrol. — A slightly irritating 
silver antiseptic solution for use in the middle ear. 

e. Fifty per cent. Solution of Argyrol. — Anon-irritating silver anti- 
septic for use in the canal. 

4. Strong Antiseptics. 

a. Corrosive Sublimate, 1-1000 Solution. — A good antiseptic solution 
for external use and for use in the canal in otitis externa circumscripta. 

b. Corrosive Sublimate, 1-5000. — A good solution for use in the 
tympanum and as an antiseptic douche in syphilitic cases and a 
few of the cases wmere solution a is ineffective. 

c. Solution of Carbolic A cid in Water, 5 per cent. — A useful antiseptic 



SPECIAL LOCAL THERAPEUTICS. 59I 

anesthetic application for the canal. Can be used as drops in 
otitis externa. 

d. Solution of Carbolic Acid in Water, 21/2 per cent. Solution. — A 
good antiseptic syringing solution for purulent otitis. 

5. Astringent Corrosive Antiseptics. 

a. Ten per cent. Chromic A cid Solution in Water. — A mild antiseptic 
astringent escharotic for the middle ear. 

b. Ten per cent. Solution of Nitrate of Silver. — Slightly escharotic to 
the middle ear and very stimulating. 

c. One Hundred per cent. Solution of Nitrate of Silver. — A stimulat- 
ing escharotic for the middle ear. 

6. Anesthetic Antiseptic. 

Solution of Carbolic Acid in Glycerine, 10 per cent. Strength. — 
An antiseptic and local anesthetic in otitis externa circumscripta. 
To be used on cotton pledgets or as an application to the canal. 

7. Antiseptic Digestant. 

Peroxide of Hydrogen. — An active antiseptic for the middle ear 
with the power of disintegrating and sterilizing accumulated detritus. 
It is an irritant. Its chief use is for rapid sterilization and disin- 
tegration of foul collections in the tympanum. 

8. External Antiseptic for Sterilizing the Operative 
Field. 

Harringt on ' 5 Solution : 

Commercial alcohol 640.0 

Hydrochloric acid 60.0 

Water 300.0 

Corrosive sublimate 0.8 

This solution is used as a means of sterilizing the operative held. 
Three minutes' exposure of the skin to the solution is sufficient for 
satisfactory sterilization. The solution should be washed off 
with sterile water. 

9. Alkaline Solution. 

Saturated Solution of Bicarbonate of Soda in Water. — Dropped 
with medicine dropper into the meatus to soften horny masses, and 
as a syringe solution for the middle ear to soften epithelium and 
cholesteomata. It is used with the large syringe or with the middle- 
ear syringe. 



592 DISEASES OF THE NOSE, THROAT AND EAR. 

io. Wound Dressings, Stimulating Antiseptics. 

a. Tincture of Iodine. — A powerful stimulant and antiseptic. A 
stimulating application to sluggish infected wounds. Especially 
useful for destroying maggots in the ear. 

b. Red Wash: 

Zinc sulphate gr.viii 

Spt. lavender comp 5 n i 

Aq ad. giv 

An antiseptic astringent stimulating wash to be used as a wet 
dressing on indolent infected wounds. 

ii. Wound Dressings; Stimulating Solutions. 

a. Balsam of Peru. — A strong stimulant for sluggish wounds. 
Should be brushed on the wound. 

b. Balsam of Peru in Oil Solution: 

Balsam of Peru 3 u i 

Castor Oil 5 xm * 

A stimulating dressing for wounds. It is to be packed in the 
wound or applied on a gauze strip. 

c. Tincture of Benzoin. — A stimulating application for sluggish 
purulent ears. 

d. Compound Tincture of Benzoin. — A less stimulating application 
than c. 

12. Wound Dressing; Sedative Antiseptic. 
Aluminum Wash: 

Acet. aluminum 5 

Acet. lead 25 

Water 500 

Shake well and dilute 1 to 4 for use. 
An astringent wash for wet dressing of infected wounds. 

13. Middle-ear Stimulants for Use in Trophopathia 
Tympanica. 

a. Glycerine Solution: 

Glycerine §i 

Acid carbolic 

Iodine aa gr.iii 

For use in the middle ear as a stimulant in trophopathia tympanica. 
Two to three minims are blown into the tympanum through the Eu- 
stachian catheter. 



SPECIAL LOCAL THERAPEUTICS. 593 

b. Benzoinol Solution: 

Acid carbolic 

Iodine aa gr.ii 

Benzoinol 3i 

For use in the middle ear as a stimulant in trophopathia tympa- 
nica. Two to three minims are blown into the tympanum through 
the Eustachian catheter. 

14. Rubefacients. 
Cantharidin Solution: 

Cantharidin i .00 

Oil 100.00 

This solution is a rubefacient for use in the canal in trophopathia 
tympanica, and on the mastoid process. 

15. Diluents; Wound Cleansers. 

a. Normal Salt Solution: 

Sodium chloride 8.00 

Water 1000.00 

This solution is used by the mouth and as a high enema in 
bacterial toxemia to assist elimination of the toxins. 

b. Isotonic Salt Solution. 

NaCl 0.59 

KC1 0.04 

CaCl 0.04 

MgCl 0.025 

NaH 2 P0 4 0.0126 

NaHC0 3 0.351 

Glucose 0.15 

Water 1000.00 

This solution is used for washing and moistening wounds. 

16. Hemostatics. 

a. Adrenalin, 1- 1000 Solution. — For use in clearing blood from 
operative fields. 

b. Adrenalin, 1-5000 Solution. — For use with cocaine as a local 
anesthetic in middle-ear operating. 

17. Collodion Solutions. 

a. Contractile Collodion. — An application for the support of relaxed 
drum membranes. It is to be painted on the relaxed area of the 
drum membrane with a line cotton applicator. 
38 



594 DISEASES OF THE NOSE, THROAT AND EAR. 

b. Flexible Collodion. — Useful for fastening small dressings on 
wounds. 



POWDERS. 

i. Boric Acid. — The best antiseptic dusting powder for use in 
the middle ear and wounds. 

2. Iodoform. — A stimulating dusting powder for use in the middle 
ear and wounds. 

3. Aristol. — A drying powder for use on convalescent wounds. 

4. Pyoktanin Blue and Boric Acid, Equal Parts. — An antiseptic 
dusting powder for use in otitis media tuberculosa. 

5. Acetanilide. — An antiseptic dusting powder. 

6. Calomel. — A dusting powder for use on luetic lesions. 

7. Xeoform. — A drying powder for use in the middle ear. 

8. Talcum. — A drying powder for use on healing wounds. 

ESCHAROTICS. 

1. Fused Bead of Nitrate of Silver. — A stimulating powerful 
escharotic for use in the middle ear and on granulating wounds. 

2. Fused Bead of Chromic Acid. — A less stimulating escharotic 
for use in the middle ear. 

3. Per chloride of Iron, Supersaturated Solution. — An astringent 
escharotic for use in the middle ear. 

4. Carbolic Acid Crystals. — An anesthetic escharotic for use in 
the middle ear. 

5. One per cent. Solution of Corrosive Sublimate in Water. — An 
escharotic and stimulating antiseptic, useful in sluggish chronic 
purulent otitis and as an application for stimulating purposes. 

UNGUENTS. 

1. Lanolin. — Used as an emollient for the skin of the canal. 
It should be applied lightly with a cotton carrier. 

2. Lanolin gz and Creolin %iii. — An antiseptic anesthetic emol- 
lient for the canal. Apply lightly with cotton carrier. 



LOCAL ANESTHETICS. 595 

3. Lassar's Paste: 

Acid salycilate gr. xv 

Starch 

Zinc oxide aa 5" 

Vaseline 5 iv 

To be spread on gauze and used for eczema of the auricle and 
surrounding skin. 



LOCAL ANESTHETICS. 

i. Cocaine 20 per cent. Water Solution. — For use in the tympanum. 

2. Camphophenique. — For use in the canal in otitis externa. 

3. Bonain Mixture: 

Cocaine 
Menthol 

Carbolic acid aa 

Add supernephrin before using 1/4. 
The best local anesthetic for operations on the skin and for 
otitis externa. 

4. Alopin 20 per cent. Solution. — For use in the tympanum when 
cocaine is contraindicated. 

AUTHOR'S BIBLIOGRAPHY. 

Collodion: Its use when the Membrana Tympani and Malleal Ligament are 
Relaxed. Jour. Laryn., Rhin. and Otol., London, 1905, vol . xx, pp. 

354-58. 
Treatment of Chronic Purulent Otitis Media, with Illustrative Cases. Internat. 

Journal of Surgery. N. Y., vol. lxxviii, 1905, p. 136. 



CHAPTER XXXVIII. 

SPECIAL INSTRUMENTS, PROCEDURES, AND APPLIANCES. 

INSTRUMENTS. 

SPECIAL OTOLOGICAL INSTRUMENTS. 

i. Rongeurs: For removing all the mastoid bone in any mastoid 
operation, except a part of a sclerosed bone, or the final clearing up 
of a bone. 

2. Scissor Forceps: For breaking down portions of the laby- 
rinthine capsule and to nip off the outer wall of the cochlea and 
promontory. These forceps are also used to break away the annulus 
tympanicus in the radical operation. 

3. Hartman's Alligator Forceps: For removing polypi, the mal- 
leus, incus, small sequestra, and any foreign bodies which it can graps. 

4. Eustachian Catheters, malleable, silver, 3 sizes. The curves 
of these catheters are easily altered to suit the individual case. 
Hard-rubber catheters have some advantages over metal catheters, 
but they are disadvantageous because of the difficulty of sterilizing 
the rubber. 

5. (a) Two ring curettes, small and medium, with malleable 
handles; (b) small ring knife. 

(a) Ring curettes : For removing foreign bodies and cerumen from 
the canal. 

(b) Small ring knife: For disarticulating and removing the 
hammer in ossiculectomy. 

6. Small Hook: For removing foreign bodies. 

7. (a) Small Triangular Scraper: For the gross removal of 
the labyrinthine capsule which covers the external semicircular 
canal, the solid angle and the promontory. 

(b) Flat scraper: For the fine removal of the labyrinthine capsule. 

(c) Pointed right-hand and left-hand scrapers: For enlarging 
an opening into the labyrinth through a semicircular canal, oval, or 
round window. 

596 



INSTRUMENTS. 



597 




Fig. 229. — 1. Rongeurs, larg~ and small. 2. Scissor forceps; 3. Alligator forceps 
(Hartman), small. 4. Eustachian catheters, malleable silver, three sizes. 5. Two 
ring curettes, small and medium, with malleable handles; small ring knife. 6. Small 
hook for removing foreign bodies. 7. Instruments for labyrinthine excavation — on 
the right, small triangular scraper; on the left, flat scraper; center, two pointed right 
and left scrapers. 8. Small middle-ear angular tenotome (Buck), malleable handle. 
9. (Myringotome. 10. Two incus hooks, right and left (Sprague). 11. Malleable 
spatula retractor, five-eighths inch wide. 12. Dura mater elevator. 13 Periosteum 
elevator. 14. Fine-angle forceps (Blake). 15. Long-shafted aural speculum. 16. 
Aural specula, assorted sizes (Gruber's). 17. Mastoid wound retractor (Jansen). 
18. On the right, middle-ear canula for powder, 2 powder blowers (Davidson"). 10. 
Middle-ear syringe and canula (Blake). 20. On the left, No. 7, piano-wire cotton ap- 
plicators for meatus (Blake); center instrument, middle-ear probe (Blake); on the right. 
instrument, middle-ear cotton applicator (Blake). 21. Three assorted middle-ear 
curettes (Blake), malleable, one straight, two different lengths of bend. 22. Three 
assorted curettes (Richards). 23. Three assorted curettes (Blake). J4. Front bent 
gouge. 



598 DISEASES OF THE NOSE, THROAT AND EAR. 

8. Small Middle-ear Angular Tenotome (Buck), Malleable 
Handle: For middle-ear tenotomy and for cutting adhesions. 

9. Myringotome; a small pointed knife with a straight cutting 
edge: For incising the drum membrane and the wall of the inner 
end of the canal; also for cutting the stapedius tendon. 

10. Incus Hooks, Right and Left (Sprague) : For bringing down 
the incus in ossiculectomy. This hook is used when the alligator 
forceps cannot hold the incus or when the incus has been displaced 
up and back. 

11. Malleable Spatula Retractor: For meningeal retraction. 

12. Dura Mater Elevator: For separating the dura mater from 
the bone before cutting the bone with a rongeur. This separation 
prevents tearing the dura mater while the fragment of bone is being 
cut off. 

13. Periosteum Elevator: For preserving the periosteum and 
elevating it from the bone before the bone is morcelled with the 
rongeur. A smaller periosteum elevator of the same pattern can 
be used in the radical and modified radical operations, to elevate 
the dermo-periosteum of the canal in order that it may be preserved 
intact for assistance in the wound repair. 

14. Fine-angle Forceps (Blake) : Useful for removing . small 
foreign bodies, small hard crusts or pieces of desquamated epi- 
thelium from the canal and middle ear. Also useful in the applica- 
tion of artificial drum membranes. 

15. Long-shafted Aural Speculum: For use in close inspection of 
the drum membrane in cases where the external canal is collapsed. 

16. Aural Specula, assorted sizes (Gruber's) : For use in different- 
sized meati. 

17. Mastoid Wound Retractor (Jansen) : One retractor is 
placed in each angle of the wound for the exposure of the excavation. 

18. Powder Blower (Davidson) : This powder blower regulates 
the dusting of powder, controlling it from a thin dust to a solid 
stream. It is used to insufflate powder into the meatus and 
middle ear and to dust wounds. This blower can be transformed 
into a middle-ear powder blower by fitting it with a short rubber 
tube to which a middle-ear canula is adjusted. 

19. Middle-ear Syringe and Canula: For syringing out the 
middle ear for discharge or epithelial crusts or for intratympanic 
application of solutions. 



INSTRUMENTS. 



599 



20. A. Piano-wire Cotton Applicator for the Meatus (Blake): 
These applicators are bent at an angle to allow inspection of the 
canal, during the process of wiping. 

B. Fine Middle-ear Probes (Blake), silver, olive tip: For explor- 
ing in the tympanum. 

C. Fine Middle-ear Cotton Applicator (Blake), silver: For 
wiping recesses of the middle ear and for medicinal applications to 
the middle ear. 




Fig. 230. — Three ounce glass piston syringe with asbestos packing. 



21. Three Middle-ear Curettes (Blake), malleable shafts, one 
straight, two bent at an angle : For removing pathological growths 
or accumulations from the middle ear. The angular limb of the 
shaft is made in two lengths for reaching different distances. The 
shafts are malleable to allow making special angles at the tip. 

22. Three Assorted Curettes (Richards) : For cutting forward into 
bone. 

23. Three Assorted Curettes (Blake) : For cutting sideways into 
bone and for enlarging an opening in the bone. 




Fig. 231. — a, Two-ounce soft rubber ear syringe; b, soft rubber syringe tip, detachable. 

24. Front Bent Gouge: For accurate carving of the mastoid bone, 
either superficial or deep. 

Fig. 230, glass piston syringe, asbestos packing: For syringing 
the meatus for removal of foreign bodies and impacted serum, or 
for washing the meatus. The syringe can be boiled. 

Fig. 231, soft rubber ear syringe, a good syringe for syringing the 
canal. Especially good for family use, as it can do little damage 



6oo 



DISEASES OF THE NOSE, THROAT AND EAR. 



and can be boiled. Rubber syringe tip, for use on a piston 
syringe to lessen danger of injury. The tip can be boiled. 

Fig. 232: 1. Otoscope: For auscultation of the Eustachian tube 
and middle ear. The ends of the tube can be fitted with glass, 
metal or bone ear pieces, or the tube may be used without the ear 
pieces. 

2. Politzer's air bag for Politzerization and catheterization. 




Fig. 232. — 1. Three feet of one-fourth inch rubber tubing for otoscope. 2. Politzer's 
air-bag. 3. Forehead mirror with five-eighths inch aperture and head-band. 4. Sie- 
gel's otoscope. 5. Ear tip for otoscope. 



In Politzerization a soft rubber tube is put on the tip of the bag. 
In catheterization the tip of the bag is shaped to fit the end of the 
catheter, but not to stick in it. In catheterization no connecting 
tube is used. 

3. The forehead mirror with a large aperture, is used to permit 
less accurate adjustment than a mirror with a small aperture. 
The focus of the mirror should not be over six inches. The head 
band may be of any pattern convenient to the operator. 



INSTRUMENTS. 



601 



4. Siegel's otoscope consists of an aural speculum with the large 
end closed air-tight with a glass plate, through which the drum- 
membrane may be observed. The barrel of the speculum is united 




Fig. 233 — Politzer Bag. 

by a tube with a rubber suction or compression bag. The tip of 
the speculum is fitted tightly into the ear so that by rarefaction or 
compression of the air in the bag, the movements which the drum 
membrane will make may be observed through the glass. 




Fig. 234.-Author's Surgical Electric Engine, held in the hand ready for use. The burr 
is seen. It has but one cutting edge. Description of motor: 3/10 horse-power; 3 
phrase; 10 volts; 15,000 revolutions per minute; 185 cycles; 2 poles; diameter 2 i/S 
inches; length of barrel, 9 1/2 inches; weight, 7 lbs. 5 ozs. 



Fig. 234. — Surgical Electric Engine: This motor can be used 
as a drill, as a burr to enlarge a bone cavity, as a fraise to cut an 
osteoplastic flap, and as a trephine. The entire motor and cords 
are sterilizable. 



602 DISEASES OF THE NOSE, THROAT AND EAR. 

Other Special Instruments. — Edelmann's Galton whistle; 
Politzer's acoumeter; Eustachian salpingoscope; Victor surgical 
engine and author's burrs; tuning forks with movable clamps — 
one 24 to 36 single vibrations, one 36 to 70 single vibrations, one 
70 to 104 single vibrations, and one for 192, 256, 512, 1,024, 2,048, 
4,096, and 8,192 single vibrations. Watch with average tick; stop 
watch; author's phonographic acoumeter for accurate voice test; 




Fig. 235. — Galton's Whistle. 

small sterilizer for gas, electricity, or alcohol — size 8x3 inches. In 
addition, the ordinary instruments — scalpels, scissors, needles, 
needle-holders, forceps, artery clamps, Sprague's ear hot-water 
bag, and fountain syringe are required. 

Sterile Dressings. — Toothpick-wipes-toothpicks wound with 
cotton at the tip; absorbent cotton; absorbent cotton pads 6x6 
inches; rubber tissue; small gauze sponges free from lint, or sea 
sponges; gauze handkerchiefs 12x9 inches; two-inch roller bandages; 
iodoform or formalin gauze strips one inch wide and one and one- 
half inches wide. 

PROCEDURES. 
TYMPANIC inflation. 

Valsalva's Method. — To innate the tympanum by Valsalva's 
method, the patient should hold the nose hermetically sealed between 
the thumb and finger, and should try to blow air out through the 
nose until the compression of the air is sufficient to force it through 
the Eustachian tube. To facilitate the passage of air into one ear, 
the patient should look toward that side and tilt the chin up. 

Politzerization or Politzer air douche. The hard-rubber tip of the 
Politzer bag is covered with a piece of soft-rubber tubing. The 
tip is then placed in the nostril of the patient. With his left hand, 
the observer closes the nostrils firmly about the tube, in order that 



PROCEDURES. 



603 



no air may escape. The patient is now told to blow hard from his 
chest into his cheeks. When the cheeks are sufficiently hard, the 
air bag, grasped firmly in the observer's right hand, is quickly 
compressed to force the air into the tympani. During the test, the 
observer should have his ear connected with the patient's ear by 
an otoscope (Fig. 232, No. 1). Air will be forced into the ears if the 




Fig. 236. — Politzerization. The covered tip of the air bag is inserted in the patient's 
nostril. The nostrils are then compressed by the first finger and the thumb of the ob- 
server's left hand, while he squeezes the bag with his right hand, meanwhile the patient 
opens the tube by one of the three methods described. The otoscope is seen in the 
patient's left ear. 



Eustachian tubes are patulous and if the velum palati is firmly 
retracted. 

Another method of Politzerization: The patient should say 
"Hook! Hook! Hook!" or "Chocolate! Chocolate! Chocolate!" 
or "Ha! Ha! Ha!" The observer squeezes the bag during the act 
of phonation. The following is the best method of Politzerization: 
the patient holds a drop of water in his mouth and swallows it on 
the word from the observer. As the observer sees the larynx rise. 
he squeezes the air-bag sharply. 



604 



DISEASES OF THE NOSE, THROAT AND EAR. 



Catheterization. — Insertion of the catheter. The observer should 
first blow through the catheter with the Politzer air-bag in order 
to be sure that the catheter is clear and contains no fluid. A medium- 
sized catheter, with a medium curve, is best. The tip of the nose 
is lifted upward by the observer's left thumb and the beak of the 
catheter, pointing downward, is inserted well into the lower meatus. 

The observer releases his hold on the handle of the catheter and 
allows the catheter to swing between the first finger and the thumb 
of his right hand. The right hand of the observer is raised until 




Fig. 237. — Introduction of Catheter; First motion: the tip of the nose is lifted by the 
thumb of the observer's left hand; the catheter is grasped by the index-finger and 
thumb of the right hand and inserted into the lower fossa of the side to be catheterized. 



the shaft of the catheter touches the upper border of the nostril. 
With gentle forward pressure, the catheter is pushed in. 

If the structure of the nose is normal, the catheter will pass 
in until it has reached the posterior pharyngeal wall. If an obstruc- 
tion is encountered, the catheter should, by slight guiding movements, 
be allowed to find its own path through. The beak of the catheter 
should not be allowed to rise out of the lower fossa, or pass over a 
spur or obstructing turbinate. If the catheter will not proceed 
on gentle forward pressure the nasal fossa should be examined and 
the catheter inserted under observation with reflected light. If, 
upon inspection, the nasal passage appears to be much obstructed, 
the end of the catheter should be gently rotated in either direction, 



PROCEDURES. 



605 



and very slight forward pressure exerted. The catheter will then 
usually go in further. If it is impossible, on gentle pressure, to 
insert the catheter, a smaller catheter may be tried or the attempt 
discontinued. 

When the catheter has been passed into the nasopharynx, 
its beak must be engaged in the tube. The tube can be found by 
several landmarks. The most accurate method is by pushing the 
catheter gently in against the posterior wall of the pharynx, then 




Fig. 238.— Introduction of Catheter: Second motion: The catheter is held lightly 
by the forefinger and thumb, and raised till the shaft touches the upper border of the 
nostril, then it is gently pushed or dropped in. 



rotating the beak of the catheter outward, directing the beak into 
the fossa of Rosenmtiller. Press the handle of the catheter slightly 
against the septum, and draw it out slowly for about one-half inch. 
In doing this, one feels the beak of the catheter slip over the alar 
cartilage of the tube. As it slips, the handle of the catheter should 
be sharply pressed against the septum, and the beak rotated upward 
and outward toward the outer canthus of the eye while the catheter 
is pushed in until it is fixed in the tube. Then with the use of the air 



6o6 



DISEASES OF THE NOSE, THROAT AND EAR. 



bag, as shown in the diagram, the air is blown through the catheter 
into the ear. 

Another method of inserting the catheter into the tube: After 
passing the beak of the catheter into the nasopharynx, the beak 
is rotated 45 toward the opposite side, and the catheter drawn 
gently outward until the beak catches on the posterior edge of the 
nasal septum. The beak of the catheter is then turned downward 




Fig. 239. — Introduction of the Catheter; Third motion: After the beak of the catheter 
has been placed in the Eustachian orifice, the catheter is grasped firmly by the ob- 
server's left middle and index-finger and thumb, while the edge of the hand rests 
firmly on the forehead of the patient. The tip of the air-bag is inserted into the cathe 
ter and the bag is squeezed. 



and toward the ear to be catheterized, making a turn of 180 . 
The shaft of the catheter is pressed against the nasal septum. 
The beak is rotated upward toward the outer canthus of the eye 
of the same side, and backward pressure made at the same time. 
The beak of the catheter will usually engage in the tube by this 
method. 

To recover the catheter it is gently grasped between the thumb 
and index-finger of the right hand, drawn outward to free it from 
the tube, released and again grasped, when it is led rather than 



PROCEDURES. 607 

pulled out. If any obstruction is met, the patient should lean his 
head down and gravity will quickly free the catheter. 

It is possible to catheterize from the opposite side, but with less 
satisfactory results. The technic of catheterizing the Eustachian 
tube from the opposite nostril is as follows: The catheter should 
have a longer curve than the catheter previously used — about one 
and one-half times as long an arc, on a radius about one-half again 
as large as the size of the first one. The catheter passed through the 
opposite nostril is engaged in the mouth of the tube by rotating the 
beak toward the ear to be catheterized, drawing the catheter gently 
out until the beak catches on the posterior edge of the septum. 
The shaft of the catheter should then be pressed sharply against the 
outer wall of the nasal fossa, making a slight backward pressure. 
At the same time the beak of the catheter is rotated slightly upward 
(15 to 20 ) when the beak will usually engage in the tube. 

In exceptionally nervous cases, cocainization of the lower fossa 
of the nose and lateral pharyngeal wall will greatly facilitate 
catheterization. The beak of the catheter easily penetrates the 
mucous membrane when it is anesthetic. Force must always be 
avoided for fear of making a false passage and thereby causing 
emphysema. 

HommeVs Massage. — This massage is applied to the tragus by 
the tip of the index-finger. The index-finger is pressed firmly 
against the cheek in front of the tragus and drawn backward until 
the tragus slips back from under the finger. 

Vibratory Massage. — This massage may be applied with any 
form of vibrator, preferably using a low rate of speed — 500 to 1,000 
impulses per minute. A rubber cup is used and vibration is applied 
to the mastoid process, external auditory meatus, and under the 
angle of the jaw. 

Syringing. — In syringing, always use warm water. The operator 
should always make sure that the return flow of the water is un- 
obstructed. In syringing for cerumen and foreign bodies, use a 
piston syringe (Fig. 230), water at 99 temperature, and a tablespoon- 
ful of borax to a quart of water. Expel all the air from the syringe 
before using. Open the external auditory meatus with the left 
hand by upward and backward traction on the auricle. Backward 
traction on the auricle should be used for adults, and downward 
traction for infants. Place the tip of the syringe just in the meatus. 



608 DISEASES OF THE NOSE, THROAT AND EAR. 

pointing it inward, upward, and backward, and use considerable 
force in propelling the water. Short sharp squeezes of the syringe, 
and relaxation on the auricle, alternately, is the best method. 
In syringing for the removal of discharge and soft material, use a 
syringe with a soft rubber tip with slight pressure (Fig. 231). 

For hot douching, use a fountain syringe with a soft-rubber tip, 
and water 108 to 112 or hotter if it does not hurt the patient. 
Apply no more force than is necessary to cause the water to flow into 
the ear. 

For middle-ear syringing, use the middle-ear syringe (Fig. 229, 
No. 19) with the solution at 99 . Expel all the air from the syringe 
before using. The syringing should be done under direct inspection 
through an aural speculum and with reflected light. 

APPLIANCES. 

Artificial Drum Heads, Tympanic Splints, and Tympanic Ballast. — 
Artificial drums of various patterns may be bought or may be made 
in the office. Paper disks of thin, sized paper can be cut to fit 
over the defect in the tympanic membrane and placed in position 
with the angle forceps or cotton carrier. Thin cotton pledgets 
moistened with vaseline can also be used to close perforations in 
the membrane. 

Tympanic splints to bring the major ossicles in better apposition 
can be made with the paper as described above and placed in the 
auditory canal, resting against the lower wall of the canal and the 
short process of the hammer. Contractile collodion, which is 
painted over the relaxed area, serves as a contracting splint when 
the drum membrane is relaxed. Tympanic ballast made of pledgets 
of cotton soaked with vaseline can be applied to the promontory 
and fenestras, when there is loss of the membrane and the major 
ossicles. 

Politzer plugs may be made of cotton soaked in cocoa-butter and 
moulded into a conical acorn-shaped plug, to fit tightly into the 
meatus. 

Sterile absorbent cotton wicks for tympanic drainage are applied 
by drawing the auricle up and back and inserting the wick with the 
angle forceps. The wicks should reach the drum, but not touch it. 
A piece of sterile cotton is placed in the concha covering the wick. 



author's bibliography. 609 

AUTHOR'S BIBLIOGRAPHY. 

A Phonographic Acoumeter. Annales del Quarto Congreso Medico Pan- 
Americano, Havana, 1906, vol. ii, pp. 221-32. 

A New Motor for Bone Surgery. Archives of Otol., N. Y., April, 1908, vol. 
xxxvii, No. 2, pp. 162-163, a ^ so Med. Record, N. Y., April, 1908, vol. 
lxxiii, No. 16, p. 872. 

The Front Bent Gouge in Cranial Surgery, Medical Record, N. Y., May 20, 
1905, vol. lxvii, No. 20, pp. 789-99. 

Demonstration of an Improved Motor Drill for Mastoid Surgery. Archives of 
Otology, vol. xxxv., No. 6, pp. 562-564. 



30 



INDEX 



THE NOSE 



Abbe, R., malignant disease of the 
nose, 148 

Abscess of septum, 125 

Accessory sinuses, anomalies of, 
62-71 
and hay fever, 173 

Accidents after septal operations, 
118 

Adams' operation for deviated sep- 
tum, 99 

Adrenalin (Takamine), 156 

Allen, C. W., rhinoscleroma, 168 

Allen, Harrison, supralabial oper- 
ation, 106 

Anosmia, 9, 169 

Antrum of Highmore, foreign body 
in, 67 
inflammation of, 58 

Artificial bridge for saddle-back 
nose, 160 

Asch's operation for deviated sep- 
tum, 113 



Bates, W. H., suprarenal solution 
for epistaxis, 156 

Beck, J. C, osteoplastic operation 
for frontal sinusitis, 79 

Bernays' sponge in epistaxis, 156 

Birkett, H. S., double translumi- 
nator, 72 

Bishop, S. S., hay fever, 173 

Bleeding polyp of septum, 144 

Bliss, A. A., on Allen's supralabial 
operation, 106'" 

Boylan, J. E., ablation of turbinate 
hypertrophy, 32 

Brown, Moreau, hydrogen dioxide 
in diagnosis of sinus dis- 
ease, 61 

Browne, Lennox, malignant trans- 
formation of benign 
growths, 145 

Bryan, J. H., acute sinusitis, 59 

antrum as a reservoir for pus, 
64 



Butlin, H. T., malignant disease of 
the nose, 148 

Calcium salts in epistaxis, 156 

Caldwell- Luc operation for empyema 
of antrum, 69 

Carter, W. W., splint for fracture 
of nose, 133 

Catarrhal diathesis, 19 

Cerebrospinal fluid discharged from 
nose, 180 

Clark's solution in hay fever, 176 

Coates, George, nosebleed and or- 
ganic disease, 151 

Cobb, F. C., fracture of nose, 131 

Cocaine in hay fever, 175 

Coley's toxin treatment for malig- 
nant disease, 94 

Collapse of nostril, 128 

of turbinate erectile tissue, 

45 
Columnar cartilage, dislocation of, 

129 
Comstock, A. B., paraffin injections, 

162 
Concha bullosa, 25-82 
Congenital occlusion of nares, 126 
Coryza, 18 

Cryer, M. H., chronic sinusitis, 60 
on probing the antrum through 

ostium, 67 
Curtis, Holbrook, hay fever, 177 
Cyst of antrum, 91 
Cyst of turbinate, 2 5 

Daly, W. H., fracture of nose, 131 
Delavan, D. B., galvanism in nasal 

atrophy, 51 
submucous incisions in nasal 

hypertrophy, 38 
Denker on massage in hay fever, 1 7 
Dentary cyst, 91 
Deviation of nasal septum, 00 
Dionin in atrophy i^St ioU . 50 
Dislocation of columnar cartilage, 

129 



6ll 



6l2 



INDEX. 



Dobell's solution, 28 

Douglas, B., emphysema of eyelid 
and ethmoid disease, 83 
punctate cauterization of hy- 
pertrophy, 3 7 

Duct of Stenson, 5 

Dunbar on hay fever, 177 

Ecchondrosis of septum, 120 
Electric cautery in nasal hyper- 
trophy, 34 
Electrolysis in atrophy, 51 

for nasal spurs, 123 
Epistaxis, 151 

Erectile tissue of turbinates, 7 
Ethmoid cells, 8 
Ethmoiditis, 8^ 
Ethvlate of sodium for nasal polvps, 

Exostosis of septum, 120 

Fibrosarcoma of nose, 146 
Fink, E., hay fever, 173 
Foreign bodies in antrum, 93 

in nasal fossae, 149 
Fracture of nose, 130 
Freer' s operation for deviated sep- 
tum, 108 
Freudenthal on nasal discharge of 
cerebrospinal fluid, 180 

on rhinoscleroma, 168 
Frontal sinus, inflammation of, 71 

Galvanism in nasal atrophy, 51 

Gibb, J. S., malignant disease of 
nose, 146 

Gleason's operation for deviated 
septum, 117 

Goldstein, M., perforations of sep- 
tum, 125 
turbinal trocar, 3 8 

Gottstein's plugs in atrophic rhin- 
itis, 50 

Graminol, 177 

Hager- Brand remedy for ' 'catarrh, ' ' 
21 

Hajek's operation for frontal sinu- 
sitis, 79 

Hall, Ffaviland, abscess of septum, 

I2 5 

Haseltine's operation for septal 
perforation, 126 

Halves, Jesse, fracture of nose, 131 

Hay fever, 170 

and the accessory sinuses, 175 

Hematoma of septum, 125 

Hemorrhage in opening the sphe- 
noidal sinus, 90 

Hopkins, F. E., malignant trans- 
formation of "myxoma," 
145 



Hopmann on nasal papilloma, 144 
Hot air in nasal disease, 41 
Hydrops antri, 90 
Hyperasplia of turbinates, 24 

Iglauer, oronasal fistula in atrophic 

rhinitis, 47 
Ingals' operation for deviated sep- 
tum, 107 
in entering frontal sinus, 76 
solution of suprarenalin, 176 
Intranasal adhesions, 128 
Jackson's operation for septal per- 
foration, 126 
Jansen's operation for frontal sinu- 
sitis, 79 
on the sphenoidal sinus, 89 
Jarvis, W. C., cold wire snare in 
turbinate hypertrophy, 31 

Kakosmia, 169 

Killian's operation for frontal sinu- 
sitis, 80 
Krieg's window resection operation, 

107 
Kuhnt's operation for frontal sinu- 
sitis, 77 
Kuyk, D. A., tuning-fork in diag- 
nosis of sinus disease, 64 
treatment of turbinate hyper- 
trophy, 37 
Kyle, Braden, operation for de- 
viated septum, 104 
hay fever, 171 

Lack's theory of polyp formation, 
136/139 ' 

Lactic acid bacilli in treatment of 
atrophy, 49 

Latent empyema of antrum, 64 

Lichtwitz on latent empyema, 64 

Lothrop's operation for frontal 
sinusitis, 77 

Luc, H., modification of Ogston's 
operation, 76 

Luckett and Horn, paraffin injec- 
tions, 162 

Lupus of nose, 164 

Mackenzie, J. X., hay fever, 171 
Malignant disease of nose, 146 

transformation of benign 
growths, 145 
Maxillary sinus, 58 
Median rhinoscopy, 14 
Medio-frontal transillumination, 73 
Moure, E. J., nasal hydrorrhea, 179 
operation for deviated septum, 
102 
Mucin in atrophy, 47 
Mucocele, 90 

Myles, R. C, dry treatment of 
sinusitis, 70 



INDEX. 



613 



Nasal calculi, 1 50 

fossae, angioma of, 143 
chondroma of, 143 
cystoma of, 143 
fibroma of, 141 
foreign bodies in, 149 
osteoma of, 143 
papilloma of, 142 
syphilis of, 1 58 
hydrorrhea, 178 
neuroses, 169 
polypi, 134 
tampons, 41 
tubes, 115, 118 
Necrosing ethmoiditis (Woakes),i34 
Negative politzerization (Sestier), 61 
Nose, anatomy of, 1 

examination of, 10 
physiology of, 8 
tuberculosis of, 164 
Nosebleed from anterior ethmoidal 
veins, 157 
and granular turbinates, 152 
and Kiesselbach's spot, 152 
and telangiectasis, 151 
Nostril filter in hay fever, 178 

Ogston's operation for frontal sinu- 
sitis, 76 

Onodi on anosmia, 169 

Organ of Jacobson, 5 

Osier, W., nosebleed and telangiec- 
tasis, 151 

Ozena, 46 

Paraffin cast for deformity after 
operation on frontal sinus 
(Curtis), 77 
injections in atrophy, 49 

in deformity from fracture, 

I 33 
for saddle-back nose, 160 
Parosmia, 9, 169 

Penghawar-d jambi in epistaxis, 155 
Perforation of septum, 124 
Pollantin, 177 
Polypi of antrum, 92 
Porter, W. G., atresia of choana, 127 

Rhinitis, acute, 18 

atrophic, 43 

caseous, 53 

catarrhal, 23 

hypertrophic, 23 

membranous, 52 

purulent, 54 

sicca, 45 
Rhinoliths, 1 50 
Rhinoscleroma, 167 
Rhinoscopy, 12 

Richardson, B. W., ethylate of 
sodium for nasal polyps, 
138 



Richardson, C. W., perforation of 
septum, 124 

Roberts, nasal deformities due to 
syphilis, 163 
pin operation for deviated 
septum, 10 1 

Roe's operation for deviated septum, 
101 

Rose cold, 170 

Rouge's operation for nasal seques- 
trum, 159 

Roughton's band, 130 

Sajous on thyroid treatment of hay 

fever, 173 
Schadle, J. E., hay fever and the 

sinuses, 174 
Schwenn on malignant disease of a 

sinus, 95 
Senn, E. J., fracture of nose, 132 
Sieur and Jacob on probing the 

sphenoidal sinus, 87 
Sinusitis, acute, 55 
chronic, 55 

microorganisms in, 56 
Skiagraphy of sinuses, 7 5 
Smith, Harmon, paraffin injections, 

162 
Sommers' solution of adrenal, 175 
Spencer, W. G., abscess of septum, 

125 

Sphenoidal sinus, 87 

Spiess, orthoform in rhinitis, 22 

Stanculeanu and Baup, micro- 
organisms in sinusitis, 56 

Stein, injections of alcohol in hay 
fever, 174 

Submucous resection of nasal sep- 
tum, 107 



Thomson, St. Clair, nasal discharge 
of cerebrospinal fluid, 180 
Transillumination, 61 
Tubercle of Zuckerkandl, or Mor- 

gagni, 5 
Tuberculosis of the nose, 164 
Turbinal trocar of Goldstein, 38 
Turbinal varix, 2 5 
Turbinate, cyst of, 2 5 
erectile tissue of, 7 
hyperplasia of, 24 
Turner, Logan, transillumination of 
frontal sinuses, 7 ; 



Ulceration of septum, 124 

Valve of Hasner, 4 
Vansant on hot air in nasal dis- 
orders, 41 
Vascular collapse of turbinate. 45 



614 



INDEX. 



Walsham, W. J., operation for 
collapse of nostril, 129 

Watson's operation for deviated 
septum, 117 

Williams, Watson, cupric electroly- 
sis in atrophy, 51 

Window resection operation for 
deviated septum, 107 

Wingrave, Wyatt, cocaine in rhin- 
itis, 21 

Woakes' theory of necrosing eth- 
moiditis, 134 



Wolff's nasal tampon for epistaxis, 

155 
Wright, J., malignant transfor- 
mation of benign growths, 

pathology of turbinate cysts, 2 5 



Yankauer, S., operation for tur- 
binate hyperplasia, 38 

Yonge, E. S., resection of nasal 
nerve for hay fever, 174 



THE PHARYNX. 



Abscess, circumtonsillar, 255 

circumtonsillar, hemorrhage 
from, 258 

retropharyngeal, 242 

of tongue, 241 
Accessory thyroid tumors, 242 
Adenectomy, accidents in, 218 

anesthesia in, 212 

hemorrhage after, 217 
Adenoids, 204 

facies of, 206, 209 

and laryngeal neoplasms, 207 

recurrence of, 219 
Adhesions of velum from syphilis, 

274 
Amygdalectomy, 230 
Amygdalothripsis (Ruault), 229 
Angina, ulceromembranous or diph- 
theroid, 262 
Aprosexia (Guye), 208 

Bifid uvula, 190 

Bliss, A. A., hemorrhage after 

adenectomy, 218 
Browne, Lennox, adenoids and 

laryngeal neoplasms, 207 



False adenoidism (Natier), 209 
French, T. R., position of patient m 

adenectomy, 214 
Fusiform bacillus of Vincent, 262 



Gargling, 252 

Gas-ether sequence in adenectomy, 
213 

Goodale, J. L., tonsillar abscess, 256 

Gradle, H., anesthesia in adenec- 
tomy, 213 

Halsted, T. H., chloroform in aden- 
ectomy, 211 
foreign body in pharynx, 277 
Hinkel, F. W., chloroform in aden- 
ectomy, 212 
hemorrhage after adenectomy, 
217 
Hooper, F. H., adenectomy, 214 
Hypertrophied tonsils, 221 
electric cautery in, 227 
recurrence of, 236 
Hypopharyngoscopy (von Eicken), 
189 



Chappell, W. F., conditions simu- 
lating adenoids, 209 
hemorrhage from circumtonsil- 
lar abscess, 258 

Chiari's incision in opening cir- 
cumtonsillar abscess, 260 

Cleft palate, 192 

Clergyman's sore throat, 197 

Clicking tinnitus, 191 

Coakley, C. G., recurrence after 
tonsillectomy, 236 

Crile, George, cocaine in adenec- 
tomy, 211 

Delavan, D. B., malignant disease 
or syphilis of tonsil, 266 

Diphtheria, 2 53 

Discission (Hoffman) in tonsillar 
abscess, 261 

Ethyl bromide and ethyl chloride in 

adenectomy, 212 
Ewing, James, chloroform in status 

lymphat icus, 211 



Kelly, Brown, pharyngomycosis and 

keratosis, 246 
Kyle, D. Braden, varieties of 

adenoids, 207 
pharyngomycosis, 245 

Laryngeal neoplasms and adenoids, 

207 
Lefferts, G. M., hemorrhage after 

tonsillotomy, 233 
Leland, G. A., treatment of tonsillar 

abscess, 261 
Leptothrix buccalis, 244 
Levy, R., hypertrophy of lingua 

tonsil, 238 
Lingual quinsy, 241 

tonsil, hypertrophy of, 238 
varix, 240 
Luschka's tonsil 205 
Lymphatism, 20(1 
Lymphoid triangle, 221 

Meyer, YVilhelm, adenoids. 214 
Mycosis pharyngis, 244 



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THE LARYNX. 



Abbe, R., radium in cancer, 334 
Alcohol applications in laryngeal 

neoplasms, 318 
Altitude in laryngeal tuberculosis, 

344 
Anchylosis of cricoarytenoid joint, 

378 
Aphonia, 290 
Asch, M. J., ecchondrosis of larynx, 

3*4 
Autoscopy (Kirstein), 292-319 

Bacillus fetidus in atrophic laryn- 
gitis, 307 

Beard, John, trypsin in cancer of 
larynx, 330 

Bernheim, primary tuberculosis of 
larynx, 336 

Bosworth, F. H., atrophic laryngi- 
tis, 307 
lipoma of larynx, 314 
sarcoma of larynx, 323 

Brady, A. J., angioma of larynx, 314 

Browne, Lennox, galvanocautery 
in the larynx, 317 

Butlin, H. T., explorative laryngo- 
fissure, 333 

Capart, treatment of singers' nodes, 

305 
Casselberry, W. E., obstacle to 

intubation in edema glot- 

tidis, 299 
Cataphoresis in tuberculosis of the 

larynx, 352 
Chappell, W. F., fibroma of larynx, 

3 11 
Chorditis tuberosa (Tiirck), 301 
Chorditis vocalis inferior (Ger- 

hardt), 305 
Chorea laryngis, 365 
Clark, J. P., cyst of larynx, 311 
Crile, G. W., malignant degenera- 
tion of benign growths, 309 

Delavan, D. B., extirpation of 

larynx, 332 
X-rays in cancer of larynx, 335 
Dilating laryngotome (Whistler)', 

355 

Fatty foods in laryngeal tuber- 
culosis, 345 



Fauvel, edema of the larynx and 
Bright's disease, 300 
after-treatment of laryngeal 
neoplasms, 322 

Formidine in tuberculous laryngitis, 
346 

Fossa innominata, 286 

Fowler, W., cricoarytenoid arthritis 
in tuberculosis, 340 

Fraenkel, B., endolaryngeal opera- 
tion in cancer of larynx, 

33° 
Freudenthal's emulsion, 350 
Fulguration in cancer of larynx, 335 

Galvanocautery in tuberculosis of 

larynx, 352 
Garel and Bernand, singers' nodes, 

3°3 
Gerhardt, lipoma of larynx, 314 
Glas, Emil, laryngeal cysts, 312 
Gleitsmann, J. W., laryngectomy 

for tuberculosis of larynx, 

35i 
Gliick, total extirpation of larynx, 

33 1 
Gottstein, mucous patches of larynx, 

358 

Gouguenheim and Lombard, en- 
dolaryngeal extirpation of 
cancer, 331 
and Tissier, galvanocautery in 
tuberculosis, 352 

Grabower, nerve terminals in ad- 
ductors and in abductors, 

377 
Grossman, position of vocal band 

in recurrent paralysis, 370 
Griinwald, cricoarytenoid anchvlosis, 

378 
Gurlt, cancer of larynx, 325 

Halsted, T. H., alcohol instillations 

in laryngeal growths, 318 
Hartley, F., complete laryngectomy, 

33 1 

Heinze, frequency of tuberculosis of 
larynx, 337 

Heryng, surgical treatment of laryn- 
geal tuberculosis. 350 

11 void fossa, 285 

1 [ysterical aphonia*, 304 



617 



6i8 



INDEX. 



Inhalations in laryngeal tuberculo- 
sis (Beverley Robinson), 

345 
Intratracheal injections in tuber- 
culosis, 352 

Jackson, Chevalier, tracheoscopy 
and bronchoscopy, 385 

Johnson, H. A., spontaneous ex- 
pulsion of papilloma, 309 

Jurasz, endolaryngeal extirpation 
of cancer, 331 

Killian-Bruenings, tracheoscopy 

and bronchoscopy, 385 

Krause, nerve section for abductor 
paralysis, 376 
surgical treatment of tuberculo- 
sis of larynx, 348 

Krishaber, cancer of larynx, 324 

Lactic acid in laryngeal tuber- 
culosis, 349 
Lake, R., formalin and lactic acid 

in tuberculosis, 346 
Laryngeal neoplasms and adenoids, 
322 
stridor and laryngeal whist- 
ling, 369 
tonsil, 288 
vertigo, 364 
Laryngismus stridulus, 366 
Laryngitis, acute, 297 
atrophic, 306 
chronic, 301 

subglottic, 305 
sicca, 306 
Laryngofissure, 320 
Laryngoscopy, left lateral position 
(M'osher) in direct, 293 
(Mermod), 292 
Larynx, anatomy of, 278 
anemia of, 296 
benign neoplasms of, 308 
carcinoma of, 324 
edema of, 299 
foreign bodies in, 380 
fracture of, 389 
hemorrhage of, 296 
hyperemia of, 296 
methods of examination, 290 
neuralgia of, 363 
neuroses of, 362 
paralysis of, 371 
physiology of, 287 
sarcoma of, 323 
spasm of, in adults, 368 
syphilis of, 3 54 
tuberculosis of, 336 
Lichtwitz, intubation tube with 
fenestra in removing lar- 
yngeal growths, 317 



Ligation of arteries in cancer of 
larynx (Dawbarn), 334 

Mackenzie, J. N., complete laryn- 
gectomy, 333 
hereditary syphilis of larynx, 

3 54 
tuberculous tumors of larynx, 
.34i 

Mackenzie, M., edema of the larynx 
and Bright's disease, 300 
external operation for laryn- 
geal growth, 320 

Makuen, G. Hudson, laryngeal 
whistling, 371 

Massei, F., atrophic laryngitis, 307 

Menthol in laryngeal tuberculosis, 
346 

Micrococcus neoformans (Doyen), 

330 
Mosher, H. P., direct examination 

of larynx, 293 
Munger, C. E., laryngeal whistling, 

37i 

Nervous cough, 366 

O'Dwyer tube in syphilitic stenosis, 

3 55 

Odynphagia in tuberculous laryn- 
gitis, 344 

Ozena laryngis (Baginski), 306 

Padley's method of removing foreign 
bodies, 387 

Paraform in tuberculous laryngitis, 
346 

Pachydermia laryngis (Virchow), 
302 
verrucosa (Virchow), 310 

Phototherapy in laryngeal tuber- 
culosis, 351 

Pomum adami, 278 

Priessnitz compress, 299 

Puncture of edematous infiltrations 
in tuberculosis (Marcet), 

347 
Pyriform sinus, 285 

Relapsing ulcerative laryngitis 
(Whistler), 358 

Rima glottidis, 286 

Ringk, incipient tuberculous laryn- 
gitis, 336 

Roe, J. O., foreign bodies in larynx, 

3 8 7 
laryngeal whistling, 370 
Roentgen ray in cancer of larynx, 

.335 
Rogers' intubation tube, 321 
Ruault, duration of cancer of 
larynx, 334 



INDEX. 619 

Sacculus laryngis, 286 Tauber, B., atrophic laryngitis, 307 

Scheppegrell, W., electric cata- Tracheoscopy and bronchoscopy, 

phoresis, 352 385 

Schmidt, Moritz, cancer of larynx, Tracheotomy in papilloma of larynx, 

3 28 . ... 322 

Schroetter, dilatation in syphilitic in tuberculosis of larynx, 351 

stenosis, 355 Trypsin, 330 

Semon, F., abductor paralysis and Turner, Logan, and Thomson, laryn- 

Semon's law, 376 geal stridor, 369 
cancer of larynx, 328 

malignant degeneration of be- Ventricle of x prolapse of, 388 

q a ■ v n \ g n £ r ° wt + hs ' 3 ° 9 Verrucous diathesis, 308 3 

Sendziak, J., thyrotomy, 334 Vocal b d trac horVia of ioa 

Shurly, E. L., bacillus of Koch as a Vocal Dana ' tracnoma ot > 3°4 

factor in tuberculosis, 33 8 massage, 303 

Simpson, W. K., intubation for noauies, 301 

fracture of larynx, 390 * 

Singers' nodes, 301 Waggett, Ernest, laryngofissure, 334 

Solis-Cohen, J., amputation of tu- Williams, Watson, relative position 

berculous epiglottis, 3 50 of arytenoids in anchylosis 

foreign bodies in air tract, 381 and in paralysis, 379 

Solis-Cohen, S., edema after appli- galvanocautery in tuberculosis 

cation of suprarenal, 300 of larynx, 352 

Spastic aphonia, 366 Wood, George B., foreign bodies in 

Syphilis ignore, 343 larynx, 381 



THE EAR 



Abscess, brain, 513, 560 
epidural, 556 
mastoid (see Mastoiditis) 
perisinus, 556 
subdural, 556 
subperichondrial, 584 
Acoumeter, Politzer's, in hearing 

test, 508 
Acute catarrhal inflammation of 
the middle ear (see Otitis 
media catarrhalis mitis) 
purulent inflammation of mid- 
dle ear (see Otitis media 
acuta virulenta) 
Adhesive processes of the middle 
ear (see Trophopathia tym- 
panica of inflammatory 
origin) 
Adenitis, mastoid, 554 
Aditus ad antrum, 396, 405, 408 
After impression hearing, 508 
Aids to hearing, mechanical and 

electric, 548 
Air bag, Politzer's, 600 
Amnesia, 479 
Ampulla, 432, 437 
Anatomy of the ear, 391-459 
Anemia of the cochlea, 542 

of the labyrinth, 475, 551 
effect of, on the ear, 564 
Anesthetics, local, 595 
Angle, solid, 411 
Annulus tendinosus, 403 

tympanicus, 394, 448 
Anotia, 514 
Antihelix, Fig. 1 50 
Antitragus, Fig. 150. 
Antiseptics, 589-592 
Antrum mastoideum, 394, 396, 406, 
410, 411, 423, 448, 449, 511 
at birth, 448 
Anvil (see Incus) 
Aphasia, 479 

Appliances for the ear, 608 
Applicators, Blake's cotton, 599 
Aprosexia as a result of ear symp- 
toms, 482 
Aqueductus fallopii anatomy, 407,409 
defect of, at birth, 450 
operative opening of, 574 
Aqueductus cochleae, 432 

vestibuli, 43 5 
Arnold's nerve, 447 



Artery, carotid, 451 

temporal, groove for, 394 
Arteries (see Blood supply) 
Aspergilli in external canal, 487 
Atrium, 400, 408 
Attic (see Epitympanum) 
Audition (see Hearing) 
Auditory canal (see Meatus) 

center, 440, 441 

hairs, 438 

process (see Process, auditory) 

tract (see Tract, auditory) 
Auricle, Fig. 1 50 

affections of the, 514-516 

contusion of, 515 

deformity of the, corrections of, 
582 

displacement of, 554 

malformations and deformities 
of the, 514 

veins of the, 424 
Autophonia, 480 
Axis of oscillation of ossicles, 469 

Bacteriemia causing ear disease, 494 

from ear disease, 561 
Balance, acoustic, 469 

impaired, 478 
Ballast, tympanic, 608 
Blood supply of the ear, 422 
Blowers, powder, Davidson's, 598 
Bone conduction (see Sound con- 
duction by bone) 
Bone, malar, 391 
occipital, 391 
parietal, 391 
petrous, anterior surface of, 420 

posterior superior angle of, 
sphenoid, 391 

temporal, articulations of, 391 
at birth, 448 

external topography of, 417 
outer surface of, 394 
sixth year, 455 
Brain abscess (see Abscess of 
brain) 
inflammation of (see Encepha- 
litis) 
operation for decompression, 
582 
Bryant's electric surgical engine, 

6ot 
Bulb, jugular. 421, 426, 573 



621 



622 



INDEX. 



Canal, auditory, external (see 
Meatus auditorius exter- 
nus) 
auditory, internal (see Meatus 

auditorius internus) 
carotid, 451 

cochlear, decription of, 432 
facial (see Aqueductus fal- 

lopii) . 
Fallopian (see Aqueductus fal- 

lopii) 
muscular, for tensor tympani 

muscle, 406 
posterior, of the chorda tym- 
pani nerve, 452 
semi-circular, anterior, 420, 432 
external, 432 

horizontal (see Canal, semi 
circular, external) 
posterior, 432 

superior (see Canal, semi- 
circular, anterior) 
spiral of cochlear nerve, 432 
Canalis reuniens, 434 

spiralis modioli cochleae, 437 
pro tensore tympani (see Canal, 
muscular) 
Canal-organ, lateral line, 461 
Capsule, labyrinthine, rarefying 
otitis of, otosclerosis (see 
Sclerosis tympanica) 
Cartilage of tube, 397 
Caftarrhal inflammation of the 
middle ear (see Otitis 
media catarrhalis mitis) 
Catheterization, 604 
Catheters, Eustachian, 596 
Cavity, tympanic (see Tympanicum) 
Cavum tympani (see Tympanum) 
Cells, mastoid, 411 
Cells, zygomatic, 409 
Center, auditory (see Auditory 

center) 
Cerebro-spinal meningitis (see Men- 
ingitis) 
Cerumen, hypersecretion of, and 

treatment of, 519 
Chain, ossicular, protective mechan- 
ism of the middle ear, 475 
movements of, 468 
Chondritis of the auricle, 516 
Chorda tympani nerve (see Nerve 

chorda tympani) 
Chronic catarrhal otitis media (see 
Otitis media catarrhalis 
mitis) 
otorrhea (see Otitis media pu- 

rulenta chronica) 

purulent inflammation of the 

middle ear (see Otitis 

media purulenta chronica) 

otitis media (see Otitis 

media purulenta chronica) 



Cochlea, anatomy of, 408 

anemia of the, 542 

cross-section, 438 

cross-section of, macerated, 437 

cupola of, 431 

helicotrema of, 437 

hemorrhage in the, 542 

hyperemia of the, 542 

inflammation of, 543 

lamina spiralis ossea of, 437 

modiolus of, 437 

scala media of, 434, 438 
scala tympanica of, 432 
scala vestibuli of, 432 
Cochleitis, 543 

Complications, intracranial, of ear 
disease, 556 

systemic of major surgical dis- 
ease 
Concha, 392 

labyrinthi (see Cochlea) 
Constitutional conditions, effects 
on the ear, 563 

treatment of ear disease, 564 
Contents, tympanic, 412 
Corti, organ of (see Organ of Corti) 
Cough reflex, aural, 447 
Crista acustica, epithelium of, in 
mammals, 462 
utriculi, 437 

helicis, 392 

tegminis, 408 

transversa, of internal auditory 
meatus, 42 1 

tubae, 407 
Crus anterior of stapes, 415 

inferior of helix of pinna, 391 

posterior of stapes, 415 

superior of helix, 391 
Cupola of the cochlea, or apex of 

cochlea, 437 
Curette, Blake's middle ear, 599 

Richard's, 599 

ring, 596 
Curve, diagrammatic, of a discord, 466 

of fundamental note, 464 

of second overtone, 464 
Curve, resultant of two notes, 464 
Cyst, excision of branchial, 584 

Deaf-mutism, 546 

tactile sound perception in, 472 
Deafness, cause of, 477 

cerebral, 545 

nerve, from affections of coch- 
lear nerve, 545 

psychical, 479 

in aged, 478 

sympathetic, 478 
Deformities due to inflammation of 
auricle, 515 

of the pinna, corrections of, 582 

tympanic, 534 



INDEX. 



623 



Depression, umbilical, of drum 

membrane, 401 
Development of the ear, 458 
Diplacusis, 480 
Diploe of mastoid, 411 
Direction of sound, physiology of 

determination of, 472 
Diseases of the ear, prevention of, 

495 
major surgical, of ear, 553 
of middle ear, 525 
of sound-perceiving apparatus, 

542 
of the ears caused by local 

injuries, 490—495 
of organ of equilibration, 548 
systemic, affecting the ear, 493 
Dressings, antiseptic for surgical 

wounds, 592 
Drugs that may cause ear disease, 494 
Drum head artificial, 478, 608 
Drumhead (see Membrana tym- 

pani) 
Drum membrane (see Membrana 

tympani) 
Ductus endolymphaticus, 434 
Ductus perilymphaticus, 433 
Dura mater, 452 
Dysacusis, 480 

Dysthesia. a subjective symptom 
of ear disease, 511 

Ear, affections of, from reflex 
causes, 493 
from extra-auricular disease, 

49 2 
skin, extending from with- 
out, 492 
drum (see Tympanum) 
inner (see Labyrinth) 
Eczema of the external auditory 

canal, 519 
Eighth nerve (see Auditory nerve) 
Elevator, dura mater, 598 

periosteum, 598 
Embryology and ontogeny, 458 
Eminence of external semi-circular 

canal, 410 
Eminentia canaliculi externi, 410 
Encephalitis, infectious, 560 
Endolymph, physiological action of 

in equilibration, 473 
Engine, surgical electric, Bryant's, 

601 
Epilepsy and aural disease, 482 
Epitympanum, 400, 405, 410 
Equilibration, mechanism of, 472 
Erysipelas of auricle, 516 
Escharotics, 594 

Eustachian tube, 395 (see also Tube, 
tympano-pharyngeal) 
blood supply of, 423 
sensory nerve, supply of, 444 



Examination, naso-pharyngeal, for 

ear disease, 505 
for subjective symptoms of ear 

disease, 511 
of patients, 496 
of the osseous part of the canal, 

497 
of the vestibular apparatus, 

Exostosis and hyperostosis of the ex- 
ternal auditory meatus, 
522 

External auditory meatus (see 
Meatus auditorius exter- 
nus) 

Fallopian canal (see Aqueductus 

fallopii) 
Fauna of the ear, 488 
Fenestra ovalis, 406, 417, 450 

rotunda, description of, 417,432 
Fibrosis tyrnpanica, 53 5 
Fissure, auditory (see Fissure tyrn- 
panica) 
Glaserian, 394, 405, 444 
of Santorini, 392 
petro-tympanic, 455 (see also 
Petro-tympanic suture) 
Fissure, tympanic, 394 
Fistula branchialis, excision of, 584 
post-aural into mastoid an- 
trum, operation for, 586 
suppurating in external audi- 
tory canal, 523 
Flora of the ear, 483 
Fluids, use of, in the naso-pharynx, 

causing ear infection, 491 
Fold, mucous of tympanum, 415,416 
of membrana tympani poster- 
ior, 402 
of posterior pocket of mem- 
brana tympani, 404 
Foramen, chordae tympani, 444 
mastoid, 394 
nerve, Jacobson's, 419 
nerve, Arnold's, 419 
of Huguier, 444 
of Huschke, 451 
singulare, 421 
stapedii, 405 
stylo-mastoideum, 41S 
subarcuatum, 452 
Forceps, Blake's fine angle, 598 
Hartman's small, 596 
scissors, 596 
Foreign bodies in the external 
auditory meatus, 517 
in meatus, operation for, 5S4 
Fork, tuning, 500 
Fossa, digastric. 410 
glenoid, 304 

inferior of internal auditory 
meatus, 42 t 



624 



INDEX. 



Fossa, intercruralis, 392 
jugular, 420 
middle, of skull, dura mater 

of, 573 
of Rosenmuller, 395, 397, 399 
posterior, of skull, dura mater 

of, 57 5 
scaphoid, 392 
subarcuate at birth, 4 50 
superior of internal meatus, 421 
Frost bites of the auricle, 515 
Functional tests in examination of 

patients, 506 
Furuncles of external auditory 
meatus, operation for, 585 
Furunculosis, 520 



Galton's whistle, 602 

Ganglion, Gasserian, depressions for, 

405 
spiral, 438 
vestibular, 442 
General circulatory disturbances 

causing ear disease, 494 
Glands, lymph, position of, 429 
Glenoid fossa, 394 
Groove, digastric, 419 

as a landmark of position of 
facial nerve, 418 
middle meningeal, 420 
occipital, 419 

of inferior petrosal sinus, 420 
of tympanic plexus, 450 
of sigmoid sinus, 450 

convexity of the, 570 
of superior petrosal sinus, 420 
Grooves of superficial petrosal 
nerves, 405 



Hairs of organ of Corti, Figs, 189, 

190 
Hallucinations, auditory, 479 
Hammer (see Malleus) 
Handle of hammer (see Manu- 
brium mallei) 
Harmony, definition of, 465 
Harrington's solution for sterilizing 

operative field, 591 
Hearing, abnormally acute, 480 
after impression, 508 
aids to, 548 
double, 480 
false, 480 

normal, in middle life, 510 
organs which give rise to sen- 
sations of, 430 
preservation of, 495 
test for, 506 

(see also under Auditory centre, 
Diplacusis, Sound and Au- 
ditory center) 



Helix, 392 

Helmholtz, theory of sound per- 
ception, objections to, 460 
Hemorrhage from the ear, 524 

in the cochlea, 542 
Heredity, role of, in some forms of 

ear disease, 494 
Herpes zoster, indications of, 517 
Hiatus of Fallopius, 420 
Hommel's massage, 607 
Hook, small, for removing foreign 

bodies, 596 
Sprague's incus, 598 
Huguier, foramen of, 444 
Hydrocephalus, infectious, 558 
Hygiene, faulty personal, causing 

ear disease, 491 
Hyperacusis, 480 
Hyperemia, and anemia of the 

labyrinth, 551 
Hyperequilibrium, 549 
Hyperostosis of external auditory 

meatus, 522 
Hypersecretion of cerumen and 

treatment, 519 
Hypertrophia tympanica, 538 
Hypo-equilibrium, 549 

Incisura intertragica, 392 

Rivini, 404, 405 

Santorini, 392 
Incus, 414 

external ligament of, 416 

hook, Sprague's, 598 

internal ligament of, 416 

posterior ligament of, 416 

to distinguish right from left, 
414 
Infant's ear, anatomy of, 448-455 

development of, 448-455 

drum membrane, 435 

Eustachian tube, 451, 4 52, 453, 

4 54 
external auditory meatus, 452 
mastoid antrum, size of, 448, 

449, 454 
process, growth, 449 
osseous labyrinth, 451 
ossicles of, 451 
position of external auditory 

meatus, 451 
sense of hearing, first appear- 
ance of, 448 
temporal bone, 448 
tympanic cavity, 451, 454 
Inflation, Valsalva, of tympanum, 

505, 602 
Influenza, bacterial infection in, 486 
cochleitis as a complication of, 

644 
secondary infection of the ear 
from the throat in, 486 
Inner ear (see Labyrinth) 



INDEX. 



625 



Insanity, tinnitus sometimes the 
exciting cause of, 479 
toxemia from ear infection caus- 
ing, 482 

Instruments, 596 

Itching of ear, causes of, 482 

Keloid caused by boring the ear, 490 

Labyrinth, 430—443 

anemia of the, 551 
blood supply of, 424 
contents of, 417 
development in vertebrates, 

455, 456 
diseases of the, as a whole, 

550—552 
surgical evacuation of, 574 
functional development of, in 

vertebrates, 456 
hyperemia of, 551 
injuries of, treatment, 550 
in the higher reptiles and birds, 

462 
membranous, 417 

description of, 434 
osseous, lining, of, 430 
macroscopic openings of, 431 
passage of the sound waves 

in man which enter the, 

464 
peripheral sense organs of, 430 
Labyrinthine capsule, rarefying 

ostitis of, in otosclerosis 

(and see Sclerosis tym- 

panica), 551 
Lamina spiralis ossea, 437 
Leptomeningitis, complications of 

(see also Meningitis), 558, 

559 
Ligament, anterior of the malleus, 
412 
external, ligament of malleus, 

412 
posterior of incus, 416 
suspensory of malleus, 4 1 2 
Ligamentum spirale, cochlear, 438 
Limbus, 411—439 
Lumbar puncture, 580 
Lymphatics, drainage of, 429 
in infant, 455 

Macula acustica sacculi, 432 
Malar bone, 391; Fig 153 
Malformations, congenital, of the 
auricle, 514 
of the external auditory canal, 

5*7 
Malleus, 4 1 2 

anterior ligament of, blood 

supply of, 412 
differentiation between left and 

right, 414 
40 



Malleus, external ligament of, 413 
handle of (see Manubrium of) 
suspensory ligament of, 400 
Manubrium of the malleus, 401 
Massage, Hommel's, 607 
Mastoid antrum (see Antrum mas- 
toideum) 
cells (see Cells) 
foramen (see Foramen mas- 

toideum) 
operation, author's modified 
radical, 571 
bandage applied in, 578 
closure of wound in, 576 
commencement of, 569 
completed, 575 
lines of incision (author's) 

for plastic of meatus, 576 
post-operative treatment, 577 
preparation and technic for, 

566-581 
primary incision for 568 
radical, 571 
process, 393 
surgery, 566-582 
tip, 406 
tubercle, 454 
Mastoiditis, complications of, 555 
diagnosis of, 553 
etiology of, 553 
indications for operation, 555 
operation for (see under Mas- 
toid operation) 
post-aural swelling, indicative 

of, 554 
presence of, how indicated, 

5 J 2 
treatment of, 554 
with subperiosteal abscess, 554 
Measles, otitis of, streptococci in, 

486 
Meatus, auditorius externus, anat- 
omy of, 392, 394 
affection of, 517 
cartilaginous, 393 
cerumen obstruction of, 51S 
blood supply of, 422 
bone caries of, 523 
herpes zoster of, 523 
hyperostosis of, 522 
injuries of, 517 
inflammation of, 519, 523 
inspection of, 417 
malformation of, 517 
neoplasm of, 522 
operative treatment of, 585 
parasites in, 522 
syphilis of, 523 
Membrana basilaris, 437 

flaccida i^see Shrapnell's mem- 
brane) 
propria membrana tympani, 
402 



626 



INDEX. 



Membrana, Reissneri, 437 

Shrapnell's (see Shrapnell's 

membrane) 
spiralis (see membrana basil- 

aris) 
tectoria, description of, 438 
tympani, 401 

abnormalities of position, 501 

oblique position of, 401 
anterior and posterior folds 

of, 404 
artificial, 478, 608 
blood supply of, 422 
changes in appearance of, 

upon inflation, 506 
color of, 500 
continuity of, examined for, 

503 
examinations of, 500 
incision of, 586 
inflammation of, 523 
in mammals, 463 
membrana propria of the, 

401 
outer surface of, 502 
perforation of, 478 
position of, 501 
posterior fold of, 402 
posterior pocket of, 404 
secundaria, 406, 432, 433 
texture of normal, 501 
umbo of, 401, 402 
Membrane of Corti (see Membrana 

tectoria,), 438 
Membranous cochlea, 437 

labyrinth, 434 
Meniere's disease, 551 
Meningitis cerebro-spinalis, 544 

presence of, how indicated, 512 
serosa, 558 
Microtia and polyotia, 514 
Middle ear (see Tympanum) " 
Mirror, forehead, 600 
Modiolus, orifice of the canal of, 
421 
spiral canal of, 437 
Mucous membrane, tympanic fold 

of, 413 
Musculus levator palati, 398, 470 
stapedius, blood supply of, 423 
contraction of, 469 
nerve supply of, 443 
tensor palati, 399 

tympani, 398, 407, 415, 469 
blood supply of, 424 
retrahens tubas, 398 
Myringitis, 523 
Myringotome, 598 
Myringotomy, 586 

Naso-pharyngeal examination of 
patients for ear disease, 

505 



Nasopharynx, inflammation of, 
causing infection of ears, 

49 2 
minor disturbances of, 563 
Neoplasms of the auricle, 517 

of the external auditory canal, 

522 
producing primary ear disease, 
489 
Nerve, Arnold's, 419 

audition (see Auditory nerve) 
auditory, central connections 

of, 439 
endings of vestibular branch 

of, 430 
resection operation, 580 
surgery of, 281 
tests for the efficiency of the, 

509 
chorda tympani, 405 
cochlear, 440 

affections of, 545 

cortical connections of, 464 
connections about the ear, 443 
deafness, 545 
facial, 406, 487 
Jacobson's, 419 
vestibular, 481 

and seasickness, 481 

central connection of, for 
equilibration, 474 

central course of, 441 

distribution of, 442 

disturbances, how indicated, 

5 12 
fibers of, 443 
Nerve-center for the appreciation of 

sounds, 429 
Nerves of the ear, 430 

temporal plexus of, 447 
Nervous system, diseases of the, a 
factor in functional changes 
of the ear, 494 
Niche of fenestra rotunda, 

in outer wall of tympanic 
cavity (see Epitympanum) 
of attic (see Epitympanum) 
of Rivini (see Epitympanum) 
Noise, a factor in ear affections, 492 
Nystagmus, cause of, 481 

Occipital bone, 394 

Ontogeny and embryology of the 

ear, 458 
Operation for decompression of 

the brain, 582 
Operation, mastoid (see Mastoid 

operation) 
Organ of Corti, 437, 462, 464 

histological structures of the, 

462 
phylogenetic development of, 

461, 462 



INDEX. 



127 



Oscillation of ossicles, axis of, 469 
Osseous labyrinth, 43 1 
Ossicles, axis of motion of, 469 

center of gravity of the, in 
erect position, 468 
• movements of the, 468 
description of, 413 
Ossiculectomy, technic of, 586 
Ostitis, rarefying of the labyrinthine 
capsule in otosclerosis, 551 
Ostium tympanicum tubse, 409 
Otalgia, cause of, 482, 511 
Othematoma, 515 

compression of, splints for, 584 
treatment of, 583 
Otic vesicle (see under Vesicle) 
Otitis, diphtheritica, 486 

externa circumscripta, 521 
diffusa, 521 

tenderness indicative of, 496 
interna, purulenta, complica- 
tions of, 555 
rubeolas, 486 

media, resultant deformities, 
treatment of, 534 
acuta catarrhalis (see Otitis 
media catarrhalis mitis) 
virulenta, 527 
diphtheritica, 446 
catarrhalis chronica (see Tro- 
phopathia tympanica) 
mitis, 525 

chronica hypertrophica 
(see Fibrosis tympanica) 
chronica non-suppurativa 
(see Trophopathia tym- 
panica) 
luetica, and sequelae, 533 
and otitis media tuber- 
culosa, differential diagno- 
sis between, 533 
purulenta a^uta (see Otitis 
media acuta virulenta) 
chronica, 530 

complications of, 532 
course of, 531 
diagnosis of, 531 
etiology of, 530 
pathology of, 530 
prognosis of, 532 
symptomatology of, 530 
treatment 'of , 531 
residua (see Otitis media 
purulenta chronica se- 
quelae,) 532 
sclerotica (see Sclerosis tym- 
panica) 
serosa (see Otitis media 

acuta virulenta) 
tuberculosa, 532 

and otitis media luetica, 
differential diagnosis be- 
tween, 533 



Otitis media, acuta virulenta, 527 
treatment, 529 

onset of, from bacteria, 485 

of scarlet fever, 486 

streptococci in, 484 

syphilitica, consequent on a 
primary lesion, 486 

tuberculosa, 486 
Otoliths, 435 

physiological action of 473, 

474 
suspended in mucus, 437 
Otorrhea chronica (see Otitis media 

purulenta chronica) 
Otosclerosis affecting the bone of 

the labyrinth, 551 
Otoscope, 601 
Outer ear, 392 
Oval window (see Fenestra ovalis) 



Pachymeningitis, 556 

Pain, reflex origin of, 482 

Palate, soft, 397 

Panotitis, 551 

Papilla acustica, 439 

Paracentesis of drum membrane or 

myringotomy, 586 
Paracusis of Willis, 479 
Para-equilibrium, 548 
Paralysis, facial, traumatic, 582 
Paresthesia a subjective symptom 

of ear disease, 511 
Parietal bone, 394 
Pathology, general, of the ear, 

483 

Pelvis of the oval window, 406 

Perception of sound (see Sound 
perception) 

Perception, test for bone, 509 

Perception of tone (see Tone per- 
ception) 

Perforation of mastoid process, 
effects of, 422 

Perichondritis of the auricle, treat- 
ment of, 516 ' 

Periostitis, swelling of the walls of 
meatus, indicating, 499 

Petromastoid bone, 452 
at birth, 450 

Phlebitis and thrombosis, 557 
diagnosis of, 557 

Phylogenesis of vertebrate ear, 455 

Physio-pathology, 477 

"Piano-string theory " of sound 
perception, 400 

Pinna, deformities of, due to super- 
abundance of cartilage, 
582 
development of, 450 

Piston syringe, 500 

Plate, auditory, 304 
tympanic, 304 



628 



INDEX. 



Plexus of nerves associated with the 
ear, 447 
tympanic, on promontory, 406, 

45° 
Plugs, Politzer's, 608 
Pocket, posterior, of membrane, 404 
Politzerization, 602 

in examination of Eustachian 
tube, 505 
Politzer's acumeter in hearing test, 
508 
air bag, 600 
Polyotia, 514 
Polypi, removal of, 587 
Porus acusticus, 409, 451 
Powder blowers, Davidson's, 598 
Powders, dusting for the ear, 594 
Probe, Blake's middle ear, 599 
Process, auditory, 394, 411 

cochleariform, 450, 451, 525 
jugular, 420, 574 
long, of incus, 404 
mastoid, 394, 419, 420, 569 
perforation of base of, and its 
effect, 422 
short, of malleus, 402 
styloid, 405, 418 
vaginal, 394 
Processus perforatus, for the stapes 

tendon, 407 
Promontory, 406, 450, 457 

in relation with tympanic 
plexus, 406 
Protective mechanism of the ear, 

474 
Prussack's fibers, 403 

space, 404, 413 
Purulent infection of the middle ear, 

acuta (see Otitis media 

acuta virulenta) 
inflammation of the middle 

ear, chronic (see Otitis 

media purulenta chronica) 
Pseudoacusis, 480 
Pyocephalus, 558 

Recessus hemiellipticus of macula 
acustica utriculi, 431 
hemisphericus of macula acus- 
tica sacculi, 431 
Reflex paths and temporal plexus 

of nerves, 445 
Reflexes, common motor, of ear, 447 
sensory of ear, occurrences of, 

447 
spasmodic, facial, 447 
Reissner's membrane, 437, 438 
Resection operation of auditory 

nerve, 580 
Retractor, Jansen's for mastoid 

wound, 597 
Spatula, 598 
Retrahens tubae muscle, 398 



Richard's curettes, 599 

Ridge, facial, 572, 575 

Ridge, temporal, 407, 454, 567 

Ring, tendinous, 403 

tympanic (see Annulus tym- 
panicus) 

Rivini, incisura, 401 

Rongeurs, large and small, 596 

Roots, of zygoma, 394, 409, 411 

Rosenmiiller' s fossa (see Fossa of 
Rosenmiiller) 

Rostrum cochleae, 407 

Round window (see Fenestra ro- 
tunda) 

Salpingitis (see under Otitis media) 
Saccule, 434 

Saliva and tear disturbances, occur- 
rence of, from ear diseases, 

447 
Santorini, fissure of, 392 
Scala media, 434, 438, 439 
tympani, 43 2, 439 
vestibuli, 432 
Scarlet fever, 486 
Scissor forceps, 596 
Sclerosis tympanica, 539 
Sclerostenosis tympanica, 536 

sequelae and complications of, 

538 
Secretory, middle ear catarrh (see 

Otitis media catarrhalis 

mita) 
Sella incudis, 404, 407, 452 

in adult tympanum, 416 
Sense, tactile, in the tunicates, 461 
Sensitive hair theory as an explana- 
tion of sound perception, 

461 
Septum tubae, 407 
Serum treatment in aural infection, 

487 
Shrapnell's membrane, 401, 402, 

403, 4i4, 454 
Sheath, cartilaginous, of malleus, 401 
Siegel's otoscope, 601 
Sigmoid sinus (see Sinus sigmoideus) 
Sigmoid sulcus, 408 
Sinus, basilar, 427 
cavernous, 427 
circular, 427 
inferior petrosal, 419, 420, 427, 

429 
lateral, 418, 427, 574 
longitudinal, 427 
occipital, 427 
petrosal superior, 420, 427, 

428 
pharyngeal, 397 (see Fossa of 

Rosenmiiller) 
phlebitis, 557 

sigmoid, 418, 426, 427, 572, 
573, 575 



INDEX. 



629 



Sinus, sigmoid, and the venous 
system, relations of, 425 
exposure of, in mastoid oper- 
ation, 574 
groove of, 420 
at birth, 450 
horizontal line of, 574 
importance of, 426 
knee of, 421, 574 
spheno-frontal, 427 
transversalis, 427 
thrombosis, 557, 572 

in connection with ear dis- 
ease, 513 
streptococci in, 483 
tympani, 406 
Sinuses, variation in size of, 428 
venous, importance of, 427 
Skin affections in the ear, 516 
Sound conduction, accommodation 
in, 469 
by air, 509, 510 
apparatus for, 468 
by air, physiology of, 466-47 1 
by bone, physiology of, 471 
test for, 509 
perception, Helmholtz theory 
of, 460 
organ of, 461 

piano-string theory of, 460 
sensitive hair theory, as an 

explanation of, 461 
tactile sense of, and deaf- 
mutes, 472 
theory of, 460 

the undifferentiated, 463 
physiology of the transmission 

of, 468 
transmission, 470 
wave, properties of, 463 
waves, 461 

conduction of, from a rarer 
to a denser medium, 466, 
467 
passage of, transmitted by 
the foot-plate of the stapes, 
471 
Space organ, peripheral (see Laby- 
rinth) 
Prussack's, 413 
Specula, Gruber's aural, 598 
Speculum, how to use, in ear ex- 
amination, 498, 499 
Sphenoid bone, 394 
Spina tegminis, 407, 459, 460 
tympani, 402 
transversa tympani, 400 
Spine of the meatus or suprameatal 

spine, 394, 396, 411, 569 
Splints, tympanic, 605 
Spongification of the labyrinth cap- 
sule or otosclerosis, 543 
Sprague's incus hooks, 598 



Squama, 420, 450, 452, 453, 454, 

57o 
Stapedius muscle, 406 
Stapes, 406, 415, 453, 457 

blood supply of, 423 

to distinguish right from left, 

4i5 
Staphylococci in otitis, 484 

responsible for chronic ear sup- 
puration, 485 
Streptococci in complicated otitis, 
484 
prevalence of, in sinus throm- 
bosis, 484 
Streptococcus encapsulatus, 483, 
484 
in otitis of measles, 486 
pyogenes a common cause of ear 
infection, 484 
Stylo-mastoid foramen, 419, 450, 

4 54 
Styloid process, 394, 409, 419, 420 

4 54 
Sulcus, sigmoid, 408 

tympanicus, 394, 403, 451 
Suppuration, acute and chronic 
effect on hearing, 532 
after operation, 485 
of labyrinth, 574 
Supramastoid ridge, or posterior 

root of zygoma, 394 
Suppuration of middle ear, acute, 
(see Otitis media acuta 
virulenta) 
chronic (see Otitis media puru- 
lenta chronica) 
Surgery, major aural, 566 

minor aural, 582 
Surgical technic, 566 
Suture, mastoideo-squamosal, 394 
petro-squamosal, 420, 450,451, 

45 2 > 454 
petro-tympanic, 452 
squamo-mastoid, 418 
squamo-petrosal, 451 
temporo-occipital, 570 
parietal, 570 
Symptoms, subjective, of ear dis- 
eases, examination for, 511 
Syphilis of the auricle and meatus, 

5 2 3 
Syringe, middle ear, and canula, 

Blake's, 598 
soft -rubber, 599 
Syringing ears, 600, 607, 60S 
Systemic complications of major 

surgical disease of the oar. 

560 



4 o , 41a, 



Tegmen antri, 401, 405, 
450, loo, 198 
mastoideum i^soe Tegmen antri) 
tympani, 407, 400, 45a, 453 



630 



INDEX. 



Temporal artery, 394 
Tenderness behind the ear con- 
sidered in diagnosis, 497 
Tendon, tensor tympani, 413, 452 
Tenotome, Buck's, 598 
Tensor palati muscle, 399 

tympani muscle, 398, 407 

accommodation and protec- 
tive action of, 469 
canal and attachment of, 415 
Test, hearing, with tuning-fork, 508, 

.5 IQ 
of air and bone conduction, 509 
watch in examination of 

patients, 507 
for bone conduction, 509 
for increased or diminished ves- 
tibular reaction, 510 
for relative and absolute air 

conductors, 509 
functional, in examination of 

patients, 506, 507 
to determine low and high 
limit of tone perception, 
508 
Theory, piano-string, of tone-per- 
ception, 460 
Therapeutics, local, 589 

anesthetic antiseptics, 591 
astringent antiseptics, 590 
hygroscopic antiseptics, 590 
mild antiseptics, 589 
strong antiseptics, 590 
of the ear, 589 
Thrombosis of sinuses of naso- 
pharyngeal origin, 557 
of the sinuses, 572 
Tinnitus, a subjective symptom of 
ear disease, 511 
aurotrophic reflexes causing, 

448 
causes of, 479 
in the mentally unbalanced, 

479 
resection of the auditory nerve 
for, 581 
Tip cells of mastoid process, 396 

mastoid, 406 
Tone, essential characteristic of, 465 
fundamental, 466 
limit, lower, 466 
upper, 465 
Tone-perception, 465 

high limit of, determined by 
Edelmann's Galton whistle, 
508 
low limit of, 507, 508, 608 
Tones of slow rate of vibration, 467 
Torus tubse, 398 
Toxemia of aural origin, treatment 

of, 561 
Tract, auditory and its connection 
with the brain, 440 



Tract, diminished activity of, as- 
sociated with arrest of 
mental development, 
483 

Tragus, 392 

Treatment, constitutional of ear 
disease, 564 

Trophic disturbances of ear, 490 

Trophopathia tympanica, diseases 
classified under, 535, 536 
middle ear, stimulants for treat- 
ment of, 502 
resulting from vaso-motor 
changes, 538 

Tube, Eustachian (see Tympano- 
pharyngeal tube) 
tympano-pharyngeal, 395, 396, 

399, 405, 407 
cartilaginous portion, 394 
isthmus of, 400 
osseous portion of, 396, 397 
mouth of, 395 
physiological function of, 

470 
secondary function of, 471 
Tuberculous otitis, 486 
Tubo-tympanitis (see under Otitis 

media) 
Tunicates, tactile sense in the, 

461 
Tuning-forks (see Fork, tuning) 
Tympanic ballast, 608 

catarrh (see Otitis media non- 

suppurativa) 
catarrh, adhesive processes in 

(see fibrosis tympanica) 
cavity (see tympanum) 
contents, 412 

fissure (see fissure tympanica) 
inflation, 602 
plate, 394 
splints, 608 
Tympanotomy, exploratory, 587 
Tympanum, acute catarrhal in- 
flammation of (see Otitis 
media catarrhalis mitis) 
purulent inflammation of 
(see Otitis media virulenta 
acuta), 
anatomy of, 405, 406, 409 
blood supply of, 423 
chronic catarrhal inflammation 
of (see Otitis media catar- 
rhalis mita) 
chronic purulent inflammation 
of (see Otitis media pu- 
rulenta chronica) 
development of, in vertebrates, 

457 r . '. 

discharge of mucus from, indic- 
ative of perforation, 500 
diseases of, 525, 540 
inflammation of, 485, 511 



INDEX. 



63I 



Tympanum, muco-purulent inflam- 
mation of (see Otitis media 
purulenta chronica) 

protective mechanism of, 475 

purulent inflammation of (see 
Otitis media acuta viru- 
lenta or otitis media puru- 
lenta chronica) 

secretory form of catarrh of 
(see Otitis media catarrh- 
alis mita) 

sound-conducting apparatus, of 
468 

suppurative inflammation of 
(see either Otitis media 
acuta virulenta or otitis 
media purulenta chronica) 

trophic disorders of (see Tro- 
phopathia tympanica) 

Umbo, 401, 402, 413, 502 
Unguents for ear diseases, 594 
Utricle, 434, Fig. 184 

Vaginal process of temporal bone, 

419, 420 
Valsalva inflation in examination of 
Eustachian tube, 505 

method of inflating the tym- 
panum, 602 
Vasomotor changes resulting from 
trophopathia tympanica, 
538 

disturbances, 447 
Vein, anterior jugular, 428 

external jugular, 428 

facial, 426 

internal jugular, 426, 428 

innominate, 426 

subclavian, 426 
Veins connected with the ear, 424, 
429 

communication of the super- 
ficial, with the intracranial 
venous system, 425 

of exit from the cranium, 428 

of the auricle, 424 

of the labyrinth, 425 

variation in relative size of, 
428 



Vena cava, superior, 426 
Venous system, intracranial, con- 
nected with the ear, 425 
of middle ear and the sigmoid 
sinus, relations of, 425 
Vertebrate ear-development of peri- 
lymphatic sac, 457 
the external ear, 457 
the tympanum of, 457 
functional development of laby- 
rinth, 456 
morphological development of 
the labyrinth, 455 
Vertebrates, labyrinth of the higher, 

462 
Vertigo, 480 

subjective, 511 
Vesicle, otic, development of, 458 
Vestibular apparatus, affected by 
bacterial invasion, 552 
nerve and tract, 442 
Vestibule, 407, 450 
Vibration, sonorous, transmission 

of, 467 
Vibratory massage for ear diseases, 
607 

Wall, internal tympanic, blood 
supply of, 424 

Watch test in examination of 
patients, 507 

Whistle, Edelmann's Galton, for 
high tone perception tests, 
508 

Wicks, sterile absorbent for tym- 
panic drainage, 608 

Willis, paracusis of, 479 

Window, oval (see Fenestra ovalis) 
round (see Fenestra rotunda) 

Wound dressings, 592 

Wounds infected, operative technic 
of the management of, 519 
of the auricle, 515 

Zygoma, 394 

anterior root of, 394 
cells of the, 409 
middle root of, 411 
posterior root of, 395 



OCT 9 1909 






SS£S? 0F CONGRESS 



021 062 805 8 



